i  —^ 


REPORT 
i  HD 

ealth  Insurance  Commission 


■  h 


PENN1T1.VANIA 

January   1919 


i 


H  I 


H A  RRIh^ ^Um^ ,    PBNN A. : 
J.  L.  L.   KUHN,   PRTNTEPv  TO  THE  (lOMMONn'^ALTH 
1919. 


OOCWMENTS 
DEPT. 


I 


REPORT 


OF  THE 


Health  Insurance  Commission 


OF 


PENNSYLVANIA 


January  1919 


^^^^TV  HARRISBURG,    PENNA. : 

J. 'l.  l.  kuhn,  printer  to  the  co^nroxwiLXLTii 

1919. 


DEPF. 


(n) 


i 

REPORT    OF   THE    HEALTH    INSURANCE    COM- 

MISSION  TO  THE  GENERAL  ASSEMBLY 

OF  THE  COMMONWEALTH  OF 

PENNSYLVANIA. 

January,  1919. 


Gentlemen : 

Your  Commission  was  appointed  under  the  Act  of  July  25,  1917, 
and  directed  to  investigate: 

1 — "Sickness  and  accident  of  employees  and  their  families,  not 
compensated  under  the  provisions  of  the  Workmen's  Compensation 
Act  of  1915,  the  loss  caused  to  individuals  and  to  the  public  thereby 
and  the  causes  thereof: 

2 — The  adequacy  of  the  present  methods  of  treatment  and  care  of 
such  sickness  and  injury; 

3 — The  adequacy  of  the  present  methods  of  meeting  the  losses 
caused  by  such  sickness  or  injury,  either  by  mutual  or  stock  insur- 
ance companies  or  associations,  by  fraternal  or  other  mutual  benefit 
associations,  by  employers  and  employees  jointly,  by  employees  alone, 
01  otherwise; 

4 — The  influence  of  working  conditions  on  the  health  of  employed 
persons ; 

5 — Methods  for  the  prevention  of  such  sickness, — all  with  a  view 
to  recommending  ways  and  means  for  the  better  protection  of  em- 
ployees from  sickness  and  accident  and  their  effects,  and  the  improve- 
ment of  the  health  of  employed  persons,  and  their  families  in  the 
Commonwealth."^ 

We  interpret  these  directions  as  imposing  on  us  the  duty  of  in- 
vestigating the  extent  and  nature  of  sickness  among  wage  workers 
and  its  economic  and  social  effects,  with  a  view  toward  making  recom- 
mendations for  the  improvement  of  existing  conditions. 

In  England  and  in  many  other  countries  of  Europe  there  are  now 
in  force  systems  of  health  insurance  under  which  wage  workers  are 
protected  against  the  sickness  risk.     The  development  of  such  in- 

? 

464834 


(*)Law8  of  Pennsylvania,  1917,  page  1199.    ^  l  "^ 

4' 


^.^Ui^itk'k'cWi'Hie^KKme.ii's  countiies  has  followed  the  growth  of  that 
system  of  i)rotectiiig  workers  against  the  economic  consequences 
of  industrial  accidents  which  this  state  has  embodied  in  the  Work- 
men's Compensation  Act  of  1915.  We  realize  that  the  princii)al  ob- 
ject of  our  appointment,  as  of  the  appointment  of  similar  Commis- 
sions in  eight  other  states,  was  to  obtain  a  report  on  the  advisability 
of  taking  in  this  state  this  next  step  in  social  insurance,  the  insurance 
of  the  employee  against  sickness. 

The  Commission  was  appointed  on  the  seventeenth  of  October, 
1917.  The  fifteen  months  which  have  since  elapsed  have  enabled  us  to 
gather  much  information  relating  to  the  extent  and  nature  of  sick- 
ness among  wage  workers  in  Pennsylvania,  its  economic  and  social 
effects  and  the  adequacy  of  the  present  methods  both  of  treatment 
and  of  meeting  the  losses  caused  by  such  sickness.  But  the  time 
and  money  at  our  disposal  have  not  been  sufficient  to  enable  us  to 
examine  thoroughly,  in  tlie  light  of  these  facts,  the  sickness  insurance 
systems  in  force  in  other  countries  or  to  consider  the  numerous  modi- 
fications of  these  systems  which  have  been  proposed  in  this  country. 
W^e  are  therefore  not  in  a  position  to  embody  in  this  report  definite 
recommendations  concerning  the  legislative  or  other  action  which 
sljould  be  taken  to  meet  the  problems  presented  by  sickness  among 
the  wage  workers  of  the  state. 

The  Commission  might  have  assumed  that  the  situation  create<l 
by  sickness  among  enqjloyed  wage  workers  in  a  great  industrial  state 
like  Pennsylvania  is  a  serious  one,  and  might  have  expended  the 
appropriation  of  |5,000  in  meetings  called  to  hear  the  advocates  and 
opponents  of  the  various  remedies  which  have  been  suggested.  But 
all  of  us  were,  and  are,  unanimoush^  opposed  to  such  a  procedure. 
We  believe,  and  we  submit,  that  the  interesting  and  important  nature 
of  the  facts  relating  to  sickness  among  the  wage  workers  of  the 
state  which  we  are  now  prepared  to  lay  before  you  justifies  the 
belief  that  a  proposition  of  such  moment  and  magnitude  as  that  in- 
volving the  general  insurance  of  all  wage  workers  against  sickness 
can  be  properly  passed  upon  only  in  the  light  of  adequate  knowledge 
of  existing  conditions. 

It  is  generally  realized  that  the  Workmen's  Compensation  Act 
deals  with  a  large  subject  of  great  difficulty  and  importance.  Some 
idea  of  the  extent  of  the  problem  which  we  have  been  directed  to  in- 
vestigate may  be  obtained  by  contrasting  tlie  amount  of  disability 
among  employees  due  to  industrial  accidents  with  the  amount  due 
to  sickness  from  other  causes. 

In  1916  there  w^ere  255,616  industrial  accidents  in  Pennsylvania 
and  3,025,371  working  days  were  lost  through  such  accidents.  In 
the  same  year  approximately  16,800,000  working  days  were  lost  on 
account  of  illness  not  due  to  industrial  accidents.    Measured  by  loss 


a 

of  ])r<)(liictive  cai)acily  and  eariiiiijj  power,  sickness  from  other  causes 
pi-odnccs  a  problem  hetirccn  five  (uul  sen  a  runes  as  ^a*eat  as  that 
produced  by  disability  resulting  from  industrial  accidents. 

For  the  reason  just  stated,  almost  our  first  action  after  our  organ- 
ization was  to  determine  to  expend  our  ajjpropriation  in  collating 
facts  already  gathered  by  public  and  private  agencies  and  as  far  as 
possible  in  instituting  and  carrying  out  original  investigations  into 
sickness  conditions  among  wage  workers  in  this  state. 

The  work  of  the  investigating  staff  of  the  Commission  was  begun 
in  May,  1918,  and  has  been  carried  on  under  the  immediate  super- 
vision of  the  Committee  on  Plan  of  Work  and  Investigation. 

The  results  of  the  investigation  are  set  forth  in  detail  in  the  Report 
of  this  Committee,  attached  as  Appendix  A.  An  examination  of  this 
Report  will  show  that  we  have  not  only  received  the  active  co-opera- 
tion of  Federal  and  State  departments  and  officials,  but  that  we 
have  also  had  great  material  assistance  from  a  number  of  private  or- 
ganizations now  dealing  with  the  social  and  economic  results  of 
poverty  and  sickness.  It  is  manifest  that  the  sum  of  |5,000  is  wholly 
inadequate  to  make  extensive  original  sickness  surveys.  The  report 
of  the  Committee,  however,  contains  the  results  of  several  studies 
made  at  the  suggestion  and  under  the  general  direction  of  our  in- 
vestigating staff,  without  expense  to  the  Commission.  The  cost  of 
making  through  our  own  staff  such  original  investigations  as  these 
would  have  amounted  to  many  times  the  a])i)ropriation  available. 

It  is  unnecessary  to  enter  here  into  any  detailed  analysis  of  the 
Report  of  the  Committee.  We  desire,  however,  to  point  out  that 
among  other  things  the  facts  obtained  show  that  in  Pennsylvania: 

I — In  regard  to  the  Extent  of  Sickness  among  Employees 

l^More  than  385,000  i)ersons  in  the  state  are  constantly 
suffering  from  illness;  approximately  140,000  from  severe, 
and  245,000  from  slighter  illnesses. 

2 — The  average  loss  of  working  time  among  employees  in  the 
]  state  is  at  least  six  days  each  year  because  of  sickness. 

3 — Pennsylvania  stood  highest  of  any  state  in  the  Union  in 
the  percentage  of  men  rejected  for  physical  reasons  in  the 
draft  of  April,  1917.  Of  her  young  men  between  twenty-one 
and  thirty-one  years  of  age,  46.07  per  cent,  were  rejected. 
The  average  for  the  country  as  a  whole  was  29.11  per  cent, 
and  one  state  had  but  14.13  per  cent,  of  her  men  rejected. 

4 — Death  rates  in  Pennsylvania  are  higher  than  those  for  the 
registration  area  of  the  country  as  a  whole.  The  infant 
death  rate — ^^that  most  sensitive  index  to  sanitary  condi- 
tions" is  highly  excessive  in  many  parts  of  the  state.     It 


was  higher  in  1917  in  Philadelphia  than  in  New  York, 
Brooklyn,  Boston  or  Chicago.  Pittsburgh  ranked  second 
among  cities  of  its  size,  having  an  infant  death  rate  of  116 
per  1,000.  The  state  as  a  whole  had  an  infant  death  rate 
in  1916  of  114  per  1,000,  while  that  for  the  whole  registra- 
tion area  was  101. 
II — In  regard  to  Losses  due  to  Sickness  of  Employees 

1 — The  losses  to  employees  consist  of  (a)  loss  of  wages  (b) 
cost  of  care  (c)  reduced  earning  power  and  standards  of 
living. 

Averages  do  not  measure  the  loss  to  individuals,  be- 
cause of  the  uneven  distribution  of  the  sickness  burden. 
In  one  of  the  sickness  surveys  in  an  industrial  district 
in  Philadelphia  each  wage  earner  sick  in  1917  lost  30 
days ;  in  another  Sickness  Survey  each  sick  wage  earner 
lost  67  days;  one-third  of  the  total  time  lost  in  this 
group  was  lost  by  nine  men,  and  three  per  cent,  of  the 
total  illness  cost  in  this  study  was  borne  by  one-seventh 
of  the  entire  number  of  families.  In  a  group  of  500  work- 
ing women  one-fourth  of  the  total  cost  of  medical  ai^ 
was  born  by  ten  of  the  women.  S 

a — At  the  nominal  rate  of  |2.00  a  daj  the  wage  loss  fo 
employees  of  this  state  every  year  because  of  illness 
is  at  least  |33,000,000. 
b — The  tendency  to  secure  needed  medical  care  has  a 
direct  relation  to  income  of  the  family.    As  the  family 
income  increases,  the  amount  spent  on  medical  care 
increases.    The  average  cost  of  medical  care  for  every 
employee's  family  is  between  |30.00  and  |50.00  a  year. 
In  the  Visiting  Nurse  Study  this  average  was  |47.00. 
Medical  charity  given  in  many  instances  cannot  he 
considered  a^  in  any  way  an  intimate  solution  of  the 
illness   prohlem   in   a   country   claiming  democratic 
ideals. 
c — Because  most  wage  earners  cannot  afford  to  he  ill, 
many   develop,  chronic   illnesses   and   greatly  reduce 
their  future  earning  capacity;  this  reacts  on  society 
by  a  direct  loss  of  productive  power  and  prevents  the 
growth  of  a  vigorous  citizenship  by  making  it  impos- 
sible to  maintain    family    standards    which    permit 
proper  nourishment,  care,   and  opportunity  for  the 
children. 
2 — The  losses  to  employers  consist  of   (a)   decrease  in  pro- 
duction due  to  the  absence  of  sick  wage  earners  or  to  the 
lessened  efficiency  of  half -sick  workers;  (b)  cost  of  labor 
turn-over. 


^ 


a — Employees  in  the  state  lose  at  least  16,800,000  days 
work  annually  because  of  sickness,  and  large  numbers 
of  actually  sick  men  and  women  are  at  work  every 
day.  These  facts,  while  not  an  exact  measure  of  the 
loss  to  industry,  give  an  indication  of  the  extent  to 
which  production  suffers.  During  the  influenza  epi- 
demic, anthracite  coal  production  dropped  behind 
500,000  tons  in  a  few  days.  There  is  constant  limita- 
tion of  production  because  of  constant  illness,  not 
spectacular,  and  therefore  not  seriously  considered. 

b — Four  large  industrial  establishments  state  that  it 
costs  on  an  average  from  |30.00  to  |50.00  to  hire  and 
train  a  new  workman.  The  greater  the  labor- turn- 
over, the  greater  the  cost  of  production;  the  greater 
the  amount  of  sickness,  the  greater  the  labor-turn-over. 
Progressive  employers  are  engaging  industrial 
[)liysicians  and  nurses,  opening  dispensaries  and  es- 
tablishing sick  benefit  funds  for  the  practical  reason 
that  it  pays  to  see  to  it  that  sick  workmen  receive  care. 

-The  losses  to  the  community  consist  of   (a)   money  loss 
(b)  social  loss. 

a — The  state  spends  over  |6,000,000  every  year  directly 
for  the  treatment  of  sickness.  In  addition,  |4,000,000 
is  spent  for  the  maintenance  of  institutions  for  the 
care  of  defectives,  a  large  part  of  which  expenditure 
is  undoubtedly  made  necessary  by  the  neglect  of  sick- 
ness and  its  consequences.  Besides  the  ten  State 
Hospitals  for  Miners  175  other  hospitals  reported  to 
the  State  Board  of  Charities  in  1916  that  57  per  cent, 
of  their  in-patients  had  been  treated  free  and  40  per 
cent,  of  their  hospital  days  had  been  free  days. 

Illness  is  no  less  a  burden  upon  private  funds. 
Aside  from  the  multitude  of  dispensaries,  hospitals, 
convalescent  homes,  visiting  nurse  societies  and  other 
charitable  and  semi -charitable  agencies  especially  for 
the  care  of  the  sick,  organized  relief  societies  invar- 
iably report  illness  to  be  the  most  frequent  disability 
in  the  families  coming  to  them  for  aid. 

b — The  loss  from  illness  to  the  community  is  not  only  in 
money  and  in  reduced  efficiency  of  the  employees 
themselves,  but  involves  the  citizenship  of  the  future. 
Growing  children,  forced  to  endure  a  period  of  under- 
nourishment because  of  straightened  family  resources 
when  the  bread-winner  is   ill — mothers  who  receive 


no  parental  care,  working  until  the  last  minute  before 
confinement  and  as  soon  thereafter  as  they  can  "stand 
on  their  feet" — babies  who  are  not  given  a  fair  start 
in  life — all  these  mean  not  only  a  present  problem, 
but  a  serious  and  unjust  handicap  for  the  generations 
to  come. 
/  There  is  no  more  important  problem  to-day  than 

safeguarding  the  health  of  the  wage-earning  woman; 
not  only  for  her  own  sake,  but  for  the  sake  of  her 
children,  whose  task  it  will  be  to  make  real  the  ideals 
for  which  our  men  have  been  laying  down  their  lives. 

Ill — In  regard  to  Present  Methods  of  Meeting  these  Losses 

1 — Facilities  for  medical  care  among  wage  earners  are  not 
satisfactory,  whether  considered  from  the  standpoint  of 
extent,  cost,*  or  proportion  of  persons  receiving  care  in  time 
of  sickness. 

Hospital  accommodations  in  the  state  average  little  more 
than  one-half  the  standard  minimum  of  five  beds  per  1,000 
of  the  population. 

Even  if  good  medical  care  were  available  and  adequate, 
most  employees  could  not  afford  to  pay  for  it.  Fees  are 
not  large,  but  wages  have  not  k^pt  pace  with  the  soaring 
cost  of  living,  save  in  a  few  groups.  Most  employees  are 
unable  to  save  toward  emergencies. 

The  result  is  that  many  of  them  fail  to  receive  medical  care 
of  any  sort^  and  that  many  more  do  not  receive  care  until 
the  illness  Jias  passed  the  stage  tchcn  it  could  he  quickly 
remedied. 

Approximately  a  fourth  of  those  actually  disabled  by  illness 
never  receive  medical  care,  and  a  larger  percentage  of  those 
ill  but  still  trying  to  work,  are  without  attention. 
The  startling  number  of  long  chronic  illnesses  found 
among  the  12,000  peojAe  in  one  Philadelphia  survey  (53.5 
per  cent,  lasting  more  than  one  year),  together  with  the  low 
proportion  of  those  ill  who  are  receiving  treatment,  makes 
obvious  the  fact  that  neglected  sick  men  often  become 
chronically  disahled,  and  that  half  sick  men  are  struggling 
to  keep  at  work  because  they  cannot  afford  to  he  ill. 

2 — Insurance  protection  against  sickness  is  found  among  ap- 
proximately 30  per  cent,  of  employees,  but  seemingly  least 
often  among  those  who  need  it  most.  Illness  is  a  thing  of 
chance  and  most  employees  take  the  chance  of  escaping  it. 
When  the  sickness  comes  they  are  stranded,  after  savings 
and  credit  have  been  exhausted.    The  lower  the  wage  group. 


the  less  likely  the  insurance  protection.  Nor  does  the 
existing  insurance  in  most  instances  meet  the  real  need.  It 
seldom  provides  good  medical  care  and  cash  'bcncrfitH,  and 
is  limited  by  many  restrictive  rules. 

One-half  to  three-fourths  of  existing  sickness  insitrance  is 
carried  through  the  sick  benefit  funds  of  the  lodges  or 
fraternals.  In  most  of  these,  sickness  insurance  is  second- 
ary to  life  insurance.  As  a  rule,  no  medical  benefits  are 
given,  and  the  cash  benefit  is  but  |5.00  a  week  for  thirteen 
weeks  in  any  single  year,  payable  only  after  a  man  has  been 
ill  more  than  two  weeks.  Trade  union  funds  rarely  afford 
better  protection.  Commercial  health  insurance  is  costly 
and  subject  to  many  restrictive  rules. 

Establishment  funds  usually  afford  better  protection,  but 
are  relatively  few  in  number  and  exist  only  among  the  most 
progressive  employers  where  health  hazards  are  frequently 
reduced  to  the  minimum. 

IV — ^In  regard  to  the  Influence  of  Working  Conditions  on  Health 

1 — Industry  is  clearly  responsible  for  a  large  proportion  of 
illness  am.ong  employees. 
.  2 — Investigations  of  the  industries  of  Pennsylvania  have  shown 
that  ^'no  other  state  has  so  wide  a  variety  of  those  in- 
dustrial processes  which  carry  with  them  danger  to  the 
workers  either  because  of  poison  in  the  form  of  fumes, 
liquids,  or  dusts,  or  because  of  mechanically  irritating 
dusts  which  injure  the  throat  and  lungs." 

3 — Seventy-nine  per  cent,  of  all  the  deaths  of  persons  of  work- 
ing age  in  1916  were  from  diseases  whose  connection  with 
"important  Pennsylvania  industries  has  been  established." 

4 — Death  rates  among  persons  of  working  age  in  Pennsylvania 
from  degenerative  diseases  due  in  large  measure  to  certain 
kinds  of  occupation,  are  steadily  increasing. 
V — In  regard  to  Sickness  Prevention 

1 — Fully  one-half  of  existing  sickness  could  be  eliminated  if 
proper  preventive  measures  were  taken. 

2 — At  present  from  70  to  75  per  cent,  of  the  school  children 
in  Pennsylvania  are  physically  defective  and  for  the  most 
part  the  defects  are  correctable  if  treated  in  time. 

3 — A  large  number  of  communities  in  the  state  have  no  active 
health  work,  much  less  an  adequate  appropriation  for 
health  activities. 

4 — Nothing  so  stimulates  preventive  effort  as  definite  respon- 
sibility for  the  losses  entailed.    Preventive  measures  proved 


8 

inadequate  to  meet  the  problem  of  industrial  accident  until 
stimulated  by  the  enactment  of  Workmen's  Compensation 
Laws.  This  form  of  social  insurance  has  steadily  reduced 
the  number  of  accidents  and  the  appeals  to  charity  from 
families  affected  and  has  proved  practical  in  administration. 
VI — Our  own  and  other  investigations  prove  that 

1 — The  responsibility  for  illness  rests  on  three  groups:  the 
community,  industry  and  the  individual.  At  present  these 
three  groups  are  meeting  the  losses  from  illness  in  wholly 
unequal  shares;  the  burden  on  the  individual  Is  often 
disastrous  and  out  of  proportion  to  his  individual  respon- 
sibility. 
Some  means  of  a  just  distribution  of  this  burden  should  be 
found. 
2 — There  is  in  Pennsylvania  today  urgent  need  for  a  program 
of  health  measures  which  will  (a)  provide  for  the  efficient 
care^  employees  and  their  femilies  when  actually  ill,  and 
(b)  provide  preventive  measures  which  will  in  so  far  as  it 
is  possible,  prevent  illness  and  increase  the  opportunity 
for  health  and  vigor  in  the  citizenship  of  the  State. 

The  problem  which  your  honorable  bodies  asked  us  to  investigate 
was  the  problem,  not  of  the  man  who  will  not  work,  or  the  man  who 
cannot  get  work,  but  the  problem  of  the  employed  worker  who  for  a 
longer  or  shorter  period  becomes  incapacitated  through  illness.  Other 
causes  of  distress  such  as  intemperance,  low  wages,  unemployment, 
ignorance  or  extravagance,  serious  though  they  are,  do  not  concern 
us,  save  as  they  are  connected  with  the  problem  of  illness.  The 
nature  of  that  problem  and  the  tragic  results  which  may  come  when 
it  is  not  solved,  are  shown  by  innumerable  life  histories  set  forth 
ill  tlie  records  of  our  charitable  institutions. 

The  story  of  a  family  whom  we  will  call  the  Callahan  family  well 
illustrates  a  typical  course  of  events:  John  Callahan  was  a  tailor, 
who  had  worked  for  a  prominent  Philadelphia  firm  for  several  years. 
He  was  the  father  of  four  small  children.  His  wages  were  not  large, 
and  as  he  was  trying  to  add  to  his  small  savings,  he  felt  he  could  not 
afford  to  be  sick,  even  when  he  contracted  tuberculosis,  due  un- 
doubtedly in  part  to  the  industrial  conditions  in  which  he  worked. 
He  denied  that  he  was  sick  and  dosed  himself  continuously  with  a 
patent  medicine,  warranted  to  "cure  all  ills."  Finally,  after  a  bad 
hemorrhage,  he  gave  up,  and  when  examined  he  was  diagnosed  as 
an  advanced  case  of  tuberculosis.  Although  his  fraternal  paid  him 
a  sick  benefit  and  in  addition  took  up  a  collection  for  him,  no  ade- 
quate help  was  available  and  the  medical  attention  had  come  too 
late.     Tlie  family,  up  to  this  time  always  self-supporting,  became 


9 

dependent  upon  a  charitable  agency.  The  children  were  all  young 
and  Mrs.  Callahan  could  not  leave  them  to  go  to  work.  Two  of 
them  were  found  to  be  tubercular,  and  Mrs.  Callahan  was  pronounced 
a  quiescent  case  of  tuberculosis.  John  Callahan  was  only  thirty- 
eight  and  the  family  had  no  resources  for  the  long  future  that 
loomed  ahead.  He  was  sent  to  Mount  Alto,  where  little  hope  is 
given  for  his  recovery;  during  the  past  three  years  the  family  has 
been  cared  for  entirely  by  private  philanthropy  at  an  expense  of 
many  hundreds  of  dollars.  The  oldest  child  is  now  only  eleven. 
Meanwhile  the  state  supports  Mr.  Callahan  in  a  public  sanitorium. 
Has  this  been  cheap  for  public  or  private  funds,  or  for  society  at 
large?  The  community  has  lost  a  self-supporting,  industrious  citizen ; 
industry  has  lost  the  productive  energy  of  a  good  worker;  Mr.  Cal- 
lahan has  lost  his  earning  power  and  his  home,  the  children  have 
suffered,  the  normal  family  unit  has  been  permanently  broken  up. 

The  Callahans  are  not  unlike  hundreds  of  other  families.  The  road 
from  independence  to  dependence  is  being  traveled  every  day  in  this 
state  by  hundreds  of  our  fellow  citizens.  It  is  the  State's  respon- 
sibility to  see  that  the  problems  of  sickness  are  reduced  to  a  minimum. 
Your  Commission  .believes  that  the  best  way  to  close  this  sickness 
high  road  to  poverty  and  dependency  is  to  make  available  immediate 
and  adequate  medical  care  for  sickness-cases  and  to  prevent  the  finan- 
cial 'burden  of  sickness  from  falling  entirely  on  the  person  least  able 
to  bear  it-r-the  sick  ivage  worker^  In  some  way  this  burden  should 
be  distributed  among  all  wage  workers,  or  shared  by  industry  and  by 
the  community  as  a  whole.  How  the  distribution  should  be  accom- 
plished, whether  by  an  extension  of  existing  voluntary  insurance 
agencies,  or  by  a  system  based  on  some  modification  of  the  English 
or  other  European  plans,  we  are  not  prepared  to  say.  In  the  time 
and  with  the  money  at  our  disposal  we  have,  as  stated,  ascertaine*! 
the  main  facts  pertaining  to  sickness  among  wage  workers  in  this 
state,  the  present  methods  of  care  of  such  sickness,  and  its  economic 
consequences. 

In  the  opinion  of  your  Commission  the  next  step  should  be  to  take 
the  facts  set  forth  in  Appendix  A.  of  this  report,  and  in  the  light  of 
these  facts  and  any  others  that  may  be  obtained,  to  make  a  thorough 
investigation  of  existing  and  proposed  plans  for  sickness  insurance 
of  employees,  with  a  view  to  making  definite  recommendations  at  the 
earliest  practical  moment  compatible  with  the  nature  of  the  subject. 

The  work  of  examining  proposed  systems  of  sickness  insurance,  of 
holding  public  hearings  in  various  parts  of  the  state,  and  of  obtaining 
the  views  of  representatives  of  the  interests  especially  effected,  is  one 
which  will  require  a  Commission  composed  of  persons  able  to  give  a 
great  deal  of  their  time  to  the  work.  Many  of  the  systems  advocated 
directly  affect  not  only  the  wage  workers  but  also  the  employers  and 


IL 


10 

tlie  ine(lical  profession,  all  of  wliicli  gioiips  sliould  be  represented  in 
the  membership  of  the  Commission. 

We  therefore  recommend  that  instead  of  continuing  this  Commis- 
sion, your  honorable  bodies  j)ass  an  Act  providing  for  the  appoint- 
ment of  a  Commission  of  eleven  persons  to  carry  on  and  complete  the 
task  of  dealing  with  one  of  the  most  vital  of  the  social  and  industrial 
problems  of  our  times;  the  Commission  to  consist  of  three  members 
from  the  Senate,  three  from  the  House  of  Representatives  and  five 
other  members  to  be  appointed  by  the  Governor,  at  large. 

We  append  hereto,  as  appendix  B,  a  copy  of  a  bill  providing  for 
the  appointment  of  such  a  Commission  as  we  suggest. 

We  respectfully  urge  the  prompt  passage  of  this  bill.  We  have 
secured  an  investigating  staff  which  could  not  be  easily  replaced, 
and  which  we  could  not  hope  to  retain  should  there  be  any  consid- 
erable delay.  Moreover,  constant  and  steady  work  on  the  i)art  of 
the  Commission,  not  from  a  period  subsequent  to  the  final  adjourn- 
ment of  your  honorable  bodies,  but  from  the  present  time,  will  alone 
in  our  opinion  insure  the  completion  of  the  task  so  that  any  recom- 
mendations may  be  thoroughly  digested  before  the  meeting  of  the 
legislature  of  1921. 

Finally,  we  hope  that  the  appropriation  of  |25,000  which  we  have 
suggested  will  meet  with  your  approval.  The  work  of  the  investigat- 
ing staff  should  be  continued,  to  which  must  be  added  a  study  of 
constitutionality  and  a  thorough  actuarial  inquiry  into  thQ  cost  of 
the  various  insurance  systems  which  it  will  be  the  duty  of  the  Com- 
mission to  examine,  while  the  Commission  will  have  to  hold  a  very 
considerable  number  of  public  hearings  and  executive  sessions.  In 
this  connection  we  desire  to  point  out  that  the  Commission  charged 
with  the  duty  of  invetigating  industrial  accidents  on  whose  report 
the  Workmen's  Compensation  Act  was  adopted  received  |1 9,800  for 
its  expenses.  The  subject  of  sickness  insurance  is,  as  has  been  in- 
dicated, one  of  greater  magnitude  and,  we  believe,  of  greater  diffi- 
culty. 

E.  E.  BEIDLEMAN, 
C.  W.  SONES, 
JAMES  B.  WEAVER. 
WILLIAM  T.  RAMSEY, 
JOHN  M.  FLYNN, 
ISADORE  STERN, 
WILLIAM  FLINN, 
WM.  DRAPER  LEWIS, 
J.  B.  McALISTER, 


APPENDIX  A. 


REPORT 

OF  THE 

Committee  on  Plan  of  Work  and  Investigation 

TO    THE 

HEALTH  INSURANCE  COMMISSION 
Commonwealth  of  Pennsylvania. 


(11) 


(12) 


APPENDIX  A. 


TABLE  OF  CONTENTS.         x 

I'ago. 

I'AIIT  I     Introductory  Summary, V.) 

Section       1  History  of  tlio  Commission, 21 

Section     II  Pennsylvania  as  an  Industrial  State 2o 

Section  III  Work  of  the  Investigating  Staff 27 

Section  IV  Conclusions  and  ReiMnnmendations, HI 

VA  nr   1 1     The  Sickness  Problem, 41 

Section  I      The  Nature  and  Ext(UJt  of  the  Sickness  Problem, 4."! 

The    Kensington    Survey,    4:'. 

The  Visiting  Nurse  Society  Study,   4r> 

Working   Women's   Records,    4J) 

Extent  of  Sickness  as  Shown  by  Sickness  Rates, .  51 

Extent  of  Sickness  as  Shown  by  Mortality  Rates, (52 

Kinds  of  Sickness, (>7 

S<'Ction  II     Losses  Due  to  Sickness,  87 

Losses   to   Employees ,     8J) 

Wages  and  Standards  of  Living, 8J) 

Loss  of  Time  on  account  of  Sickness, 95 

Loss  of  Money  on  Account  of  Sickness, J>5 

Cost  of  Medical  Care,    UG 

Loss  of  Future  Earning  Power  on  Account  of  Sickness,.  . .  .  100 

Losses  to  Industry, 100 

Losses  to  the  State 104 

^  Sickness  and  Poverty, 108 

Section  III     The  Adequacy  of  Present  Methods  of  Care, 139 

Physicians  in  Pennsylvania, 141 

Hospital  Facilities  in  Pennsylvania, 141 

Medical  Care  Received  by  Employees  and  Their  Families, 143 

Existing  Health   Insurance  in  Pennsylvania, 147 

Section  IV     Influence  of  Working  Conditions  on  Health, 1G7 

Influence  of  Working  Conditions  on  Health, 109 

Occupational  Diseases  in  Pennsylvania, 180 

Section  V     Sickness  Prevention 197 

I»ART  III     Health   Insurance, 215 

Section       1     Social  Insurance,    217 

Section     II     Health  Insurance  in  Europe, 219 

Section  III     State  Social  Insurance  Facilities  in  the  United  States,....  243 


(13) 


li 


MEMBEK8  OF  THE  HEALTH  IXSUKANCE  COMMlHSiON. 

^  APPOINTED  FROM  THE   SENATE 

HON.  EDWARD  E.  BEIDLEMAN 
HON.  CHARLES  W.  SONES 
HON.  JAMES  B.  WEAVER 

APPOINTED  FROM  THE  HOUSE  OF  REPRESENTATIVES 
HON.  WILLIAM  T.  RAMSEY 
HON.  JOHN  M.  FLYNN 
HON.  ISADORE  STERN 

APPOINTED  BY  THE  GOVERNOR 
HON.  WILLIAM  FLINN 
DR.  WILLIAM  DRAPER  LEWIS 
DR.  J.  B.  McALISTER 

EDITH  HILLES,  Executive  Secretary. 
ELIZABETH  McSHANE,  Assistant  Secretary. 


To  the  Members  of  the  Health  Insurance  Commission, 
Commonwealth  of  Pennsylvania: 

Gentlemen:   Your  Committee  on  Plan  of  Work  and  In- 
vestigation present  herewith  their  report. 

January — 1919. 


(15) 


(16) 


17 


No.  414. 
AN  ACT 

To  establish  a  commission  to  investigate  sickness  and  accident,  not  compensated 
under  the  Workmen's  Compensation  Act  of  one  thousand  nine  hundred  and 
fifteen,  of  employed  persons  and  their  families,  and  to  make  an  appropriation 
for  such  commission. 

HEALTH  INSURANCE  COMMISSION. 

Section  1.  Be  it  enacted,  &c.,  That  a  commission  is  hereby  created, 
to  be  known  as  the  Health  Insurance  Commission,  which  shall  inves- 
tigate: 

SUBJECTS  OP  INVESTIGATION. 

1.  Sickness  and  accidents  of  employees  and  their  families,  not 
compensated  under  the  provisions  of  the  Workmen^s  Compensation 
Act  of  one  thousand  nine  hundred  and  fifteen,  th^  loss  caused  to  in- 
dividuals and  to  the  public  thereby,  and  the  causes  thereof ; 

2.  The  adequacy  of  the  present  methods  of  treatment  and  care 
of  such  sickness  and  injury; 

3.  The  adequacy  of  the  present  methods  of  meeting  the  losses 
caused  by  such  sickness  or  injury,  either  by  mutual  or  stock  insur- 
ance companies  or  associations,  by  fraternal  or  other  mutual  benefit 
associations,  by  employers  and  employees  jointly,  by  employees  alone, 
or  otherwise; 

4.  The  influence  of  working  conditions  on  the  health  of  employed 
persons;  and, 

5.  Methods  for  the  prevention  of  such  sickness, — all  with  a  view 
to  recommending  ways  and  means  for  the  better  protection  of  em- 
ployees from  sickness  and  accident  and  their  effects,  and  the  im- 
provement of  the  health  of  employed  persons  and  their  families  in 
the  Commonwealth.  The  commission  shall  hold  public  hearings  in 
different  parts  of  the  Commonwealth.  The  commission  shall  submit 
a  full  final  report,  including  such  recommendations  for  legislation, 
by  bill  or  otherwise,  as  in  its  judgment  may  seem  proper,  to  the 
General  Assembly  of  nineteen  hundred  and  nineteen. 

APPOINTMENT  OF  THE  COMMISSION. 

Section  2.  Members. — The  commission  shall  consist  of  three  Sen- 
ators, to  be  appointed  by  the  President  pro  tempore  of  the  Senate, 
three  Kepresentatives,  to  be  appointed  by  the  Speaker  of  the  House 
of  Representatives;  and  three  other  persons,  not  members  of  the 
General  Assembly,  to  be  appointed  by  the  Governor. 

POWERS. 

Section  3.  Powers. — ^^The  commission  shall  have  power  to  elect 
its  chairman  and  other  officers,  to  examine  witnesses,  books,  and 
papers  res]>ecting  all  matters  to  be  investigated,  to  issue  subpoenas, 
to  compel  the  attendance  of  witnesses  and  the  production  of  books 

2 


18 

and  papers,  to  administer  oaths,  to  employ  a  secretary,  experts  in 
the  matters  to  be  investigated,  and  all  necessary  clerical  and  other 
assistants,  to  purchase  books  and  all  necessary  supplies,  and  to  rent 
halls  for  hearings.  If  the  commission  shall  appoint  from  its  members 
sub-committees  to  make  an  inquiry,  the  sub-committees  shall  have 
the  same  powers  for  the  examination  of  persons  and  papers  and  to 
administer  oaths  as  are  herein  conferred  upon  the  commission. 
Salaries  and  other  expenses  of  the  commission  shall  be  paid  upon 
vouchers  approved  by  the  chairman  of  the  commission,  up  to  the 
amount  appropriated  by  the  General  Assembly. 

CO-OPERATION. 

Section  4.  Co-operation  of  other  departments. — The  Commissioner 
of  Healtli  and  tlie  Commissioner  of  Labor  and  Industry  are  hereby 
directed  to  co-operate  with  the  commission,  and  to  render  it  any  such 
proper  aid  and  assistance  as  in  their  judgment  may  not  interfere  with 
the  proper  conduct  of  their  respective  departments;  and,  as  far  as 
possible,  rooms  in  buildings  owned  or  leased  by  the  Commonwealth 
shall  be  assigned  to  the  commission  for  hearings  or  other  purposes. 

APPROPRIATION. 

Section  5.  Appropriation. — The  sum  of  five  thousand  dollars 
(|5,000),  or  so  much  thereof  as  may  be  necessary,  is  hereby  specifi- 
cally appropriated  for  the  actual  and  necessary  expenses  of  the  com- 
mission in  the  carrying  out  the  provisions  of  this  act.  Payment  of 
the  money  shall  be  on  order  of  the  chairman  of  the  commission  and 
on  warrant  of  the  Auditor  General. 

Approved— The  25th  day  of  July,  A.  D.  1917. 

MARTIN  G.  BRUMBAUGH. 


PART  I. 
INTRODUCTORY  SUMMARY. 


(19) 


(20) 


21 


PART  I. 

SECTION  I. 

History  of  the  Commission. 


During  the  session  of  1917,  the  problems  created  by  illness  among 
the  employees  of  the  state  were  brought  to  the  attention  of  the 
Pennsylvania  Legislature  by  the  introduction  of  a  bill  providing  for 
a  state-wide  system  of  compulsory  Health  Insurance.  Many  persons 
and  agencies  interested  in  social  welfare  and  progress  had  been  in- 
strumental in  securing  the  passage  of  a  Workmen's  Compensation 
Law  in  the  state,  and  had  noted  with  great  interest  the  success  with 
which  such  laws,  transplanted  from  Europe,  had  been  put  into  opera- 
tion in  this  country.  Since  Workmen's  Compensation  is  but  a  part  of 
a  comprehensive  social  insurance  system  in  force  in  many  European 
countries,  by  means  of  which  protection  is  afforded,  not  only  against 
injury,  but  also  against  sickness,  old  age,  and  unemployment,  the 
possibilities  of  successfuly  adopting  other  features  of  the  system 
suggested  itself  to  the  authors  of  the  bill. 

The  bill  was  carefully  considered  by  the  committee  to  which  it  was 
referred  and  a  public  hearing  on  it  was  largely  attended. 

The  discussion  at  that  time  brought  out  strikingly  the  need  for  a 
thorough  study  of  health  conditions  among  employees  and  their  fam- 
ilies in  the  state,  and  resulted  in  the  introduction  of  a  bill  creating 
an  unsalaried  Commission  to  conduct  the  investigation  and  present 
a  report  to  the  Legislature  of  1919.  This  bill  was  passed  as  No.  414 
of  the  Acts  of  the  Legislature  of  1917. 

At  the  first  meeting  of  the  Commission,  on  December  28,  1917,  in 
Philadelphia,  Hon.  Edward  E.  Beidleman  was  elected  Chairman,  and 
Hon.  Isadore  Stern,  Secretary  and  Treasurer.  A  Committee  on  Plan 
of  Work,  consisting  of  Dr.  Lewis,  Mr.  Kamsey  and  Mr.  Stern,  was 
appointed  and  charged  with  the  duty  of  formulating  a  plan  for  the 
work  of  the  Commission,  taking  into  consideration  the  limited  appro- 
priation of  Jjf!5,000  which  had  been  made  for  the  work. 

This  Committee  secured  the  advice  of  Mr.  Miles  M.  Dawson  and 
Dr.  T.  M.  Rubinow,  consulting  actuaries,  and  on  May  13,  1918,  sub- 
mitted a  report,  recommending  a  careful  investigation  by  trained 
workers. 

This  report  was  accepted,  and  Dr.  McAlister  was  made  an  addi- 
tional member  of  the  Committee,  which  was  authorized  to  open  an 


22 

office  and  engage  an  investigating  staff  to  carry  on  the  work  for 
three  months,  until  August  15th.  At  that  time  a  preliminary  report 
was  to  be  submitted.  The  sum  of  |2,175  was  appropriated  for  the 
expenses  of  the  investigation  during  this  period.  The  office  of  the 
Commission,  802  Franklin  Bank  Building,  was  officially  opened  on 
May  15th,  at  which  time  the  work  of  investigation  was  actively  begun 
under  the  direction  of  Miss  Edith  Hilles. 

At  a  meeting  of  the  Commission  held  on  July  19th,  an  additional 
|2,100  was  appropriated  for  continuing  the  investigation  after 
August  15th,  and  the  Committee  on  Plan  and  Work  and  Investiga- 
tion was  designated  as  the  finance  committee  to  act  with  the 
treasurer. 

The  Preliminary  Keport  was  submitted  as  planned  and  has  been 
used  as  the  suggestive  basis  for  the  remainder  of  the  investigation. 
In  December  it  was  agreed  to  devote  the  remaining  funds  of  the  Com- 
mission to  the  completion  of  the  report. 

The  members  of  the  Committee  on  Plan  of  Work  and  Investigation 
have  conferred  from  time  to  time  with  authorities  on  the  subject 
of  Health  Insurance,  and  have  been  in  constant  touch  with  the  work 
of  the  investigation. 


PART  I. 
SECTION  II. 

Pennsylvania  as  an  Industrial  State. 


The  importance  of  Pennsylvania  as  an  industrial  state  serves  to 
emphasize  the  importance  of  the  health  of  her  wage  earners.  Health 
is  the  greatest  asset  of  the  wage  earner,  and  no  other  single  factor  has 

80  close  a  relation  to  his  efficiency.  We  realize  this  strikingly  at  the 
time  of  a  great  epidemjc,  when  suddenly  with  no  warning  industry 
after  industry  is  crippled,  and  output  seriously  lowered,  because  em- 
ployees are  ill.  Yet  constantly,  year  in  and  year  out,  preventable 
illness  goes  on,  lowering  efficiency  and  output,  causing  great  social 
and  economic  w^aste,  and  we  pay  little  attention,  because  it  is  not 
spectacular. 

According  to  the  census  of  1910,  Pennsylvania  ranked  second  only 
to  New  York  in  the  total  number  of  persons  gainfully  employed  in 
her  industries,  and  in  the  value  of  her  manufactured  products.  Per- 
sons gainfully  occupied  numbered  3,130,681,  or  more  than  one  tenth 
of  the  total  number  in  this  group  in  the  United  States.^ 

These  gainfully  occupied  persons  constituted  more  than  half  of  the 
total  population  in  Pennsylvania  over  ten  years  of  age ;  and  included 

81  per  cent,  of  the  men,  and  21  per  cent,  of  the  women  of  the  state. 
The  proportion  of  men  and  women  gainfully  occupied  was  approxi- 
mately one  woman  to  four  men.  The  occupations  where  women  were 
most  numerous  were  trade  with  16.1  per  cent.,  manufacturing  and 
mechanical  with  17.3  per  cent.,  clerical  with  30  per  cent.,  the  profes- 
sional group  with  42.1  per  cent.,  and  domestic  and  personal  service 
where  68  per  cent,  were  women.  This  was  the  only  group  where  the 
number  of  women  exceeded  the  number  of  men.^ 

Some  23  per  cent,  of  these  gainfully  occupied  persons  were  classi- 
fied, in  1910,  as  ''laborers.''  The  next  largest  group  belonged  to  the 
classification,  ''manufacturing  and  mechanical,"  which  comprised  19.3 
per  cent.  Agricultui'e,  extraction  of  minerals,  trade  and  domestic 
service  included  11.6  per  cent.,  10.4  per  cent.,  9.3  per  cent.,  and  9.6 
per  cent.,  respectively,  and  the  other  16  per  cent,  were  divided  be- 
tween transportation,  public  service  and  professional  and  clerical 
work.3 

It  is  interesting  to  note  the  geographical  distribution  of  these 
groups. 


(')A  list  of  the  Pennsj'lvania  industries  employing  more  than  100,000  persons  is  given  as  Table 
I  at  the  end  of  Part  I. 

(2) See  Table  II  at  end  of  Fart  I. 
(«)See  Tab'e  III  at  end  of  Part  I. 


24 

Forty-two  per  cent,  of  the  gainfully  occupied  were  in  the  twenty 
cities  in  the  state  having  a  population  of  over  25,000.  Fifty-eight  per 
cent,  were  distributed  among  the  smaller  cities,  towns  and  the  rural 
districts.  Seven  hundred  and  eleven  thousand,  one  hundred  and 
sixty-nine,  or  23  per  cent.,  were  centered  in  Philadelphia,  and  233,637, 
or  seven  per  cent.,  were  in  Pittsburgh. 

The  proportion  of  "laborers"  employed  in  the  Pittsburgh  district 
far  exceeded  the  proportion  in  the  state  as  a  whole.  Thirty-nine  and 
four-tenths  per  cent,  of  the  workers  in  this  district  were  classified  as 
"laborers,"  while  the  percentage  for  the  whole  state  was  23.1  and  for 
the  Philadelphia  district,  but  13.3.  The  influence  of  the  steel  mills 
is  obvious. 

On  the  other  hand  36.7  per  cent,  of  the  workers  in  Philadelphia 
were  in  the  "manufacturing  and  mechanical"  group,  while  in  the 
state  as  a  whole  there  were  but  19.3  per  cent.,  and  in  Pittsburgh  less 
than  10  per  cent,  so  classified. 

It  would  be  difficult  to  over-emphasize  the  industrial  importance 
of  Pennsylvania  or  the  diversified  character  of  her  industries. 

In  1914,  before  war  time  expansion  began,  293,370  persons  were 
employed  in  the  great  steel  works,  rolling  mills  and  other  branches 
of  the  metal  trades  in  the  state,  and  124,986  in  the  textile  industry. 
Of  the  1,065,000  workers  employed  in  mining  in  the  United  States  in 
1910,  nearly  a  third,  or  357,671,  were  found  in  the  coal  mines  of 
Pennsylvania.  It  is  well  known  that  Pennsylvania  leads  all  the 
states  of  the  union  in  mining  and  that  practically  the  entire  anthra- 
cite coal  supply  of  the  country,  including  certain  smokeless  varieties 
required  by  the  navy,  is  produced  within  this  state.  A  third  of  the 
bituminous  coal  as  well  comes  from  Pennsylvania.  When  the  in- 
fluenza epidemic  reduced  the  coal  output  suddenly  the  whole  country 
felt  it,  and  it  was  to  Pennsylvania  that  the  country  looked  for  in- 
creased production  later,  to  make  up  this  loss. 

Besides  producing  coal,  steel,  ships,  chemicals  products,  hosiery, 
knit  and  woolen  goods,  Pennsylvania  is  doing  her  full  share  in  feed- 
ing the  nation.  Approximately  65  per  cent,  of  her  land  is  devoted 
to  agriculture,  and  in  1910  she  produced  farm  crops  valued  at 
1147,000,000  and  gave  employment  to  362,000  agricultural  workers, 
or  11.6  per  cent,  of  the  total  number  of  persons  ten  years  and  over 
gainfully  occupied  in  the  state. 

During  the  Great  War  tremendous  demands  were  made  upon 
Pennsylvania ;  it  became  a  center  for  war  contracts  and  for  "essential 
industries."  A  quarter  of  all  the  war  contracts  let  during  the  first 
months  of  our  participation  were  located  in  Pennsylvania  and  Ohio. 
Pittsburgh,  long  recognized  as  the  greatest  center  for  the  iron  and 
steel  industry,  became  the  site  of  heavy  artillery  plants.  In  the  east, 
along  the  Delaware  River,  approximately  100,000  men  were  employed 
in  ship  building.!    It  has  been  suggested  that  the  Delaware  be  called 

(>) Authorized  statement  of  Henry  R.  Seager  of  the  Shipbuilding  I^bor  Adjustment  Board,  May 
28,   1018. 


25 

^•The  Clyde  of  America"  but  the  reply  was  made  that  the  Clyde  was 
instead  "The  Delaware  of  England,"  for  the  the  magnitude  of  Ameri- 
can construction  far  exceeds  the  British  output. 

If  merely  the  rate  of  increase  of  the  decade  1900  to  1910  had  been 
maintained  between  1910  and  1918,  by  the  latter  year  the  number  of 
gainfully  occupied  persons  would  have  risen  to  3,827,257.  In  reality, 
owing  to  the  wartime  expansion  of  Pennsylvania  industries,  a  con- 
siderably higher  number  of  persons  are  probably  at  work  in  the  state 
at  the  present  time.  It  is  usually  estimated  that  not  more  than  25 
per  cent,  of  the  workers  are  proprietors  of  their  own  farms  or  busi- 
nesses, so  that  it  may  safely  be  said  that  there  are  now  more  than 
2,800,000  employees  in  the  state. 

To  investigate  the  health  problems  of  these  2,800,000  employees  has 
been  the  task  of  the  Commission.  In  an  industrial  state  the  cost  of 
sickness  to  industry  alone  is  tremendous.  Output  depends  very 
largely  on  the  individual  worker,  and  the  efficiency  of  the  wage  earner 
depends  in  large  measure  upon  his  health,  and  the  health  of  his 
family.  The  United  States  Public  Health  Service  estimates  that 
each  wage  earner  in  the  United  States  loses  on  an  average  nine  days 
work  each  year  because  of  sickness.  Physicians  and  sanitary  experts 
tell  us  that  at  least  half  of  this  loss  is  due  to  illness  which  could  be 
prevented.  The  facts  which  we  have  collected  lead  us  to  believe  that 
large  numbers  of  Pennsylvania  employees  are  each  year  rendered 
incapable  of  working  with  their  highest  efficiency  because  of  a  general 
lack  of  proper  measures  for  the  preservation  of  public  health  and 
because  of  the  neglect  of  many  minor  ailments  which,  untreated, 
often  develop  into  serious  disabilities.  We  know  the  stimulus  to 
preventive  effort  and  to  prompt  treatment  in  cases  of  industrial 
accidents  which  has  come  because  of  the  enactment  of  Workmen's 
Compensation  laws.  Mr.  Harry  A.  Mackey,  Chairman  of  the  Penn- 
sylvania Workmen's  Compensation  Board,  stated,  in  January  1917, 
"No  statistician  can  ever  calculate  the  tremendous  advantage  to  the 
industries  of  Pennsylvania  or  to  society  generally,  because  of  the  fact 
that  this  law  has  furnished  to  nearly  200,000  men  free  medication  so 
successfully  administered  that  they  have  been  cured  of  all  resulting 
complications  or  infection — and  their  injuries  have  not  become  com- 
pensable." 

If  the  Commission  can  suggest  methods  which  will  reduce  the  time 
lost  by  Pennsylvania  workers  through  sickness,  and  which  will  make 
more  nearly  possible  the  maintenance  of  proper  health  standards,  it 
will  not  only  have  given  valuable  help  to  the  industrial  Avorld,  but 
will  have  made  a  permanent  contribution  to  the  character  of  our 
citizenship. 


(20) 


PART  I. 
SECTION  III. 

Work  of  the  Investigating  Staff. 


The  general  scoi)e  of  the  investigation  possible  was  determined  on 
the  one  hand  by  the  Commission's  requirement  of  a  preliminary  re- 
port on  August  15th,  to  be  used  as  a  basis  in  deciding  whether  or  not 
to  continue  the  work  beyond  that  date,  and  on  the  other  hand  by  the 
five  general  lines  of  study  outlined  by  the  Act  creating  the  Commis- 
sion and  used  by  the  staff  as  a  foundation  for  all  work: 

1.  Sickness  and  accident  of  employees  and  their  families  not  cov- 
ered by  workmen's  compensation. 

2.  Loss  resulting  from  sickness  to  individuals  and  the  public. 

3  Adequacy  of  the  present  methods  of  meeting  the  financial  loss 
from  illness  and  giving  medical  treatment  and  care. 

4  Influence  of  working  conditions  on  health. 
5.     Sickness  prevention. 

In  view  of  the  limited  time  and  money  at  its  disposal,  the  Com- 
mission realized  that  material  already  in  print  must  be  utilized  to  the 
fullest  possible  extent  and  that  the  field  work  done  in  Pennsylvania 
must  be  in  a  large  measure  by  means  of  free  aid  from  existing  organ- 
izations either  co-operating  independently  with  the  Commission  or 
working  under  the  direct  supervision  of  the  staff. 

This  policy  has  been  adopted,  and  we  believe  it  has  produced  more 
favorable  results  than  might  have  been  expected.  In  so  far  as  the 
staff  can  learn  of  its  existence,  all  printed  matter  bearing  specifically 
on  the  Pennsylvania  conditions  about  which  the  Commission  was 
required  to  report  has  been  collected  and  studied,  together  with  the 
more  recent  and  significant  general  material.  Unfortunately  much 
of  this  local  printed  matter  was  found  to  be  so  superficial  or  in- 
•  accurate  that  it  was  impossible  to  use  it. 

For  our  field  work  we  have  been  most  fortunate  in  securing  the 
co-operation  of  representative  social  and  educational  agencies  in 
various  parts  of  the  state,  and  of  several  state  and  national  depart- 
ments. We  have  attempted  so  to  plan  our  investigations  that  they 
would  represent  the  different  sections  of  the  state,  both  industrially 
and  geographically. 

Money  limitations  have  prevented  special  studies  among  the  min- 
ing and  rural  population  which  could  not  have  been  made  except 
through  our  own  staff.  However,  seven  organizations  have  undertaken 
special  studies  for  ui,  and  only  one  of  these  studies  is  unfinished; 


28 

three  of  tlie  seven  are  state-wide  in  scope.  Seven  other  organizations 
have  compiled,  or  segregated,  special  material,  and  in  many  instances 
unpublished  studies  of  great  value  have  been  secured.  In  this  con- 
nection we  have  especially  appreciated  the  co-operation  of  the  United 
States  Bureau  of  Labor  Statistics,  the  Pennsylvania  Department  of 
Labor  and  Industry,  the  Pennsylvania  Department  of  Health,  the 
Metropolitan  Life  Insurance  Company,  the  Morris  Plan  Company  of 
IMiiladelphia,  the  Pennsylvania  Old  Age  Pension's  Commission  and 
the  Ohio  Health  and  Old  Age  Insurance  Commission. 

Special  thanks  are  due  the  Philadelphia  Bureau  of  Municipal  Ke- 
search,  and  the  sixteen  volunteer  workers  who  from  time  to  time  gave 
their  services.  In  addition  to  these,  the  staff  wishes  to  record  its 
hearty  appreciation  of  the  services  of  the  many  persons,  private  or- 
ganizations and  official  bureaus,  whose  help  and  co-operation  have 
made  this  report  possible. 

A  list  of  the  special  studies  made  for,  or  by,  the  Commission  and 
used  constantly  in  this  report,  follows: 

I — Kensington  Sickness  Survey  made  by  the  students  of  the  Penn- 
sylvania School  for  Social  Service  in  Philadelphia,  in  May 
and  June,  1918.  This  was  a  house  to  house  canvass  of  743 
families,  containing  3,198  persons,  in  a  census  enumeration 
district  in  Kensington,  carefully  selected  to  insure  its  repre- 
sentative character.  The  primary  purpose  of  the  study  was 
to  get  the  illness  history  of  these  families  for  the  year  end- 
ing April  1,  1918,  but  the  cases  of  sickness  existing  at  the 
time  of  the  survey  were  also  noted.  Disabling  and  slighter 
illnesses  were  not  distinguished. 

II — Sickness  Histories  of  Special  Groups. 

A — Sickness  and  Dependency.  A  study  of  1,500  of  the 
families  in  which  illness  was  a  problem,  under  the 
care  of  the  Charity  Organization  Societies  of  seven 
cities  in  the  State,  during  1917. .  This  study  was 
made  by  the  societies  and  tabulated  by  the  Commis- 
sion and  by  the  students  of  the  Carnegie  Institute  of 
Technology,  Pittsburgh,  under  the  direction  of  Irene 
Farnam  Conrad. 
B — Sickness  History  of  Working  Girls.  A  study  of  502 
members  of  Young  Women's  Christian  Association 
Industrial  Clubs  in  seventeen  cities  of  the  State. 
This  covered  the  illness  histories  of  these  working 
girls  for  the  period  June,  1917,  to  June, 
1918.  Wage  figures  and  occupations  for  1914,  be- 
fore the  war,  were  obtained  for  comparative  pur- 
poses. This  study  was  made  by  the  Association 
Secretaries  and  tabulated  by  the  Commission. 


2^ 

C — Sifkiicss  llisloi-y  of  Wn'j^v  i^juiicrs'  Fjniiilies.  A 
study  of  500  families  given  nursing  service  in  July,^ 
1918,  by  the  Philadelphia  Visiting  Nurse  Society. 
The  families  were  not  limited  to  a  jjarticular  group, 
but  were  chosen  consecutively.  The  illness  at  the 
time  of  the  visit  was  disregarded,  but  the  sickness 
history  for  the  preceding  year  was  obtained.  This 
study  was  made  by  the  nurses  of  the  Society,  and 
tabulated  by  the  Commission. 

I) — Sickness  History  of  Wage  Earners.  A  study  of  the 
fatal  illness  of  the  fathers  of  families  now  under  the 
care  of  the  Mothers'  Assistance  Fund  in  Lancaster 
and  Lackawanna  Counties.  This  study  was  made  by 
agents  of  the  Mothers'  Assistance  Fund  and  tabu- 
lated in  the  office  of  the  State  Supervisor,  Harris- 
burg. 

Ill — Studies  of  Health  Hazards  in  Industry. 

A — Occupational  Diseases  in  Pennsylvania.  An  article 
prepared  especially  for  the  Commission  by  Dr. 
Alice  Hamilton,  United  States  Bureau  of  Labor 
Statistics,  November,  1918. 

B — Factory  Health  Conditions.  A  study  of  100  factories 
in  the  Pittsburgh  district,  made  during  the  sum- 
mer and  fall  of  1918  by  the  Women  in  Industry 
Division  of  the  Council  of  National  Defense  of  Alle- 
gheny County. 

IV — Studies  of  Existing  Insurance  Facilities. 

A — Special  study  of  the  sick  benefit  funds  of  the  Penn- 
sylvania Kailroad  (lines  east),  J.  G.  Brill  Company, 
J.  B.  Stetson  Co.,  Nelson  Valve  Company  and 
Tabor  Manufacturing  Company,  made  by  the  Com- 
mission in  co-operation  with  the  Ohio  Health  and 
Old  Age  Insurance  Commission. 

^a^^8^^,  B — Brief  study  of  existing  commercial  insurance  com- 

HH|P  panics,  trade  union  and  fraternal  sick  benefit  funds 

^  in  Pennsylvania ;  made  by  the  Commission. 

In  addition  to  these  special  studies,  two  sickness  surveys  are  used 
so  constantly  in  the  report  that  a  brief  description  of  them  here 
seemed  advisable.     Other  sources  are  explained  in  the  text. 

A  sickness  survey  of  seven  districts  in  Philadelphia  was  made  in 
1917  by  nurses  from  the  city  Bureau  of  Health,  under  the  direction 
of  the  Chief  of  the  Bureau  of  Vital  Statistics.  Five  southern  dis- 
tricts of  the  city  were  covered  by  a  house-to-house  canvass  in  August, 


80 

and  a  district  in  Manayunk  and  one  in  Germantown  were  added  in 
mid-September.  The  study  included  12,019  individuals  in  2,655  dif- 
ferent families,  and  covered  all  sickness  existing  at  the  time  of  the 
survey,  and  duration  to  that  date.  The  enumerators  were  instructed 
to  work  slowl}^  and  carefully  and  to  win  the  confidence  of  the  families 
whom  they  visited.  When  the  information  secured  seemed  to  be  in- 
complete, families  were  revisited,  sometimes  as  often  as  three  times. 
In  view  of  the  precautions  taken,  we  may  assume  that  the  sickness 
rate  is  reasonably  accurate,  although  the  time  of  year,  August  and 
September,  was  one  at  which  sickness  is  at  the  minimum.  This 
survey  will  hereafter  be  referred  to  as  the  Philadelphia  Survey. 

A  study  of  sickness  conditions  in  the  principal  cities  of  central  and 
vv^estern  Pennsylvania,  including  Pittsburgh,  was  carried  on  in  1917 
among  industrial  policyholders  of  the  Metropolitan  Life  Insurance 
Company.  The  enumerators  were  the  regular  agents  of  the  com- 
pany, who  gathered  the  survey  facts  in  the  course  of  their  door-to-door 
collections.  The  study  was  made  in  March,  "a  time  of  year  when 
physical  disability  on  account  of  disease  is  probably  at  its  maximum," 
and  covered  328,051  persons,  a  much  larger  number  than  was  reached 
by  the  Philadelphia  Survey,  but  only  "serious  cases  of  sickness'^  ex- 
isting at  the  time  of  the  survey  were  noted.  This  survey  will  hereafter 
be  referred  to  as  the  Western  Pennsylvania  Survey.  As  the  figures 
for  Pittsburgh  have  been  tabulated  separately,  they  will  be  referred 
to  as  the  Pittsburgh  Sickness  Survey. 


:n 


PART  I. 

SECTION  IV. 

Conclusions  and  Recommendations. 


CONCLUSIONS. 


EXTENT  OF  SICKNESS  AMONG  EMPLOYEES. 

I — More  than  385,000  persons  in  the  State  are  constantly  suffer- 
ing from  illness;  approximately  140,000  from  severe,  and 
245,000  from  slighter  illnesses. 

II — The  average  loss  of  working  time  among  employees  in  the 
state  is  at  least  six  days  each  year  because  of  sickness.  In 
1916,  3,025,071  working  days  were  lost  because  of  industrial 
accidents  in  the  State;  sickness  causes  approximately  five 
to  seven  times  as  much  loss  as  industrial  accidents. 

Ill- — Pennsylvania  stood  highest  of  any  state  in  the  Union  in  the 
percentage  of  men  rejected  for  physical  reasons  in  the  draft 
of  April,  1917.  Of  her  young  men  between  twenty-one  and 
thirty-one  years  of  age,  46.67  per  cent,  were  rejected.  The 
average  for  the  country  as  a  whole  was  29.11  per  cent.,  and 
one  State  had  but  14.13  per  cent,  of  her  men  rejected. 

IV — Death  rates  in  Pennsylvania  are  higher*  than  those  for  the 
registration  area  of  the  country  as  a  whole.  The  infant 
death  rate — "that  most  sensitive  index  to  sanitary  condi- 
tions" is  highly  excessive  in  many  parts  of  the  State.  It 
was  higher  in  1917  in  Philadelphia  than  in  New  York, 
Brooklyn,  Boston  or  Chicago.  Pittsburgh  ranked  second 
among  cities  of  its  size,  having  an  infant  death  date  of  116 
per  1,000.  The  State  as  a  whole  had  an  infant  death  rate 
in  1916  of  114  per  1,000,  while  that  for  the  whole  registra- 
tion area  was  101. 

LOSSES  DUE  TO  SICKNESS  OF  EMPLOYEES. 

I — The  losses  to  employees  consist  of  (a)  loss  of  wages  (b)  cost 

of  care  (c)  reduced  earning  power  and  standards  of  living. 

Averages  do  not  measure  the  losses  to  individuals,  because 

of  the  uneven  distribution  of  the  sickness  burden.     In  one  of 

the  Sickness  Surveys  in  an  industrial  district  in  Philadelphia 

3 


32 

each  wage  earner  sick  in  1917  lost  thirty-eight  days.  In  an- 
other Sickness  Survey  each  wage  earner  lost  sixty-seven  days : 
one- third  of  the  total  time  lost  in  this  group  was  lost  by  nine 
men,  and  53  per  cent,  of  the  total  illness-cost  was  borne  by 
one-seventh  of  the  entire  number  of  families.  In  a  study  of 
Working  Women  one-fourth  of  the  total  cost  of  medical  care 
was  borne  by  ten  of  the  women. 

(a)  At  the  nominal  rate  of  $2.00  a  day  the  wage  loss  to  em- 

ployees of  this  State  every  year  because  of  illness  is  at 
least  133,000,000. 

(b)  The  tendency  to  secure  needed  medical  care  is  in  direct 

relation  to  income  of  the  family.  As  the  family  in- 
come increases,  the  amount  spent  on  medical  care  in- 
creases. The  average  cost  of  medical  care  for  every 
employee's  family  is  between  |30.00  and  |50.00  a  year. 
In  the  Visiting  Nurse  Study  this  average  was  $47.00. 
Medical  Charity  given  in  many  instances  cannot  'be 
considered  as  in  any  way  an  untimate  solution  of  the 
illness  problem  in  a  country  claiming  democratic 
ideals. 

(c)  Because  most  wage  earners  "cannot  afford  to  be  ill," 

many  develop  chronic  illnesses  and  greatly  reduce  their 
future  earning  capacity;  this  reflects  an  inestimable 
loss  to  society  in  productive  power,  vigorous  citizen- 
ship, and  the  possibility  for  maintining  family  stand- 
ards which  permit  proper  nourishment,  care,  and  op- 
portunity for  the  children. 

II — The  losses  to  industry  consist  of  (a)  decrease  in  production 
due  to  the  absence  of  sick  wage  earners  or  to  the  lessened 
efficiency  of  half -sick  workers;  (b)  cost  of  labor  turn-over. 

(a)  Employees  in  the  State  lose  at  least  16,800  000  days 

work  annually  because  of  sickness,  and  large  numbers 
of  actually  sick  men  and  women  are  at  work  every 
day.  These  facts,  while  not  an  exact  measure  of  the 
loss  to  industry,  give  an  indication  of  the  extent  to 
which  production  suffers.  During  the  influenza  epi- 
demic anthracite  coal  production  dropped  behind 
500,000  tons  in  a  few  days.  A  constant  limiting  of 
production  exists  at  all  times  because  of  constant  ill- 
ness, not  spectacular  and  therefore  not  seriously  con- 
sidered. 

(b)  Four  large  industrial  establishments  state  that  it  costs 

on  an  average  from  |30.00  to  |50.00  to  hire  and  train  a 
new  workman.  The  greater  the  labor  turn-over,  the 
greater  the  cost  of  production ;  the  greater  the  amount 
of  sickness,  the  greater  the  labor  turn-over.  Some  pro- 
gressive employers  are  engaging  industrial  physicians 
and  nurses,  opening  dispensaries  and  establishing  sick 
benefit  funds  as  a  business  principle;  because  it  pays 
to  see  to  it  that  sick  workmen  receive  care. 


33 

111 — The  losses  to  the  commuiiity  consist  of   (a)   money  loss;    (b) 
social  loss. 

(a)  The  State  spends  over  |6  000,000  every  year  directly  for 

the  treatment  of  sickness.  In  addition,  |4,000,000  is 
spent  for  the  maintenance  of  institutions  for  the  care 
of  defectives,  a  large  part  of  which  expenditure  is  un- 
doubtedly made  necessary  by  the  neglect  of  sickness 
and  its  consequences.  Besides  the  ten  State  Hospitals 
for  Miners,  175  other  hospitals  reported  to  the  State 
Board  of  Charities  in  1916  that  51  per  cent,  of  their 
in-patients  had  been  treated  free  and  40  per  cent,  of 
their  hospital  days  had  been  free  days. 
Illness  is  no  less  a  burden  upon  private  funds.  Aside 
•  from  the  multitude  of  dispensaries,  hospitals,  con- 
valescent homes,  visiting  nurse  societies  and  other 
charitable  and  semi-charitable  agencies  especially  for 
the  care  of  sickness,  organized  relief  societies  in- 
,  variably  report  illness  to  he  the  most  frequent  dis- 
ahility  in  the  families  coming  to  them  for  aid. 

(b)  The  loss  from  illness  to  the  community  is  not  only  in 

money  and  in  reduced  efficiency  of  the  employees 
themselves,  but  involves  the  citizenship  of  the  future. 
Growing  children,  forced  to  endure  periods  of  under 
nourishment  because  of  straightened  family  resources 
when  the  breadwinners  are  ill — mothers  who  receive 
no  prenatal  care,  working  until  the  last  minute  before 
confinement  and  as  soon  thereafter  as  they  can  "stand 
on  their  feet" — babies  who  are  not  given  ^  fair  start  in 
life — all  these  mean  not  only  a  present  problem,  but  a 
serious  and  unjust  handicap  for  the  generations  to 
come. 
There  is  no  more  important  problem  today  than  safe- 
guarding the  health  of  the  ivage-earning  woman;  not 
only  for  her  own  sake,  but  for  the  sake  of  her  children, 
ichose  task  it  tcill  be  to  make  real  the  ideals  for 
which  our  men  have  been  laying  down  their  lives. 

PRESENT  METHODS  OF  MEETING  THE  SICKNESS  PROBLEM. 

I — Facilities  for  medical  care  among  wage-earners  are  not  satis- 
factory, whether  considered  from  the  standpoint  of  extent, 
cost,  or  proportion  of  persons  receiving  care  in  time  o^  sick- 
ness. Hospital  accommodations  in  the  State  average  little 
more  than  one-half  the  standard  minimum  of  five  beds  per 
1,000  of  the  population.  Even  if  good  medical  care  were 
available  and  adequate,  most  employees  could  not  afford  to 
pay  for  it.  Fees  are  not  large,  but  wages  have  not  kept 
pace  with  the  soaring  cost  of  living,  save  in  a  few  groups. 
Most  employees  are  unable  to  save  toward  emergencies. 
The  result  is  that  many  of  them  fail  to  receive  medical  care 
of  any  sort,  and  that  many  more  do  not  receive  medical  care 


34 

until  the  illness  has  passed  the  stage  when  it  could  be 
quickly  remedied.  Approximately  a  fourth  of  those 
actually  disabled  by  illness  never  receive  medical  care,  and 
a  larger  percentage  of  those  ill  but  still  trying  to  work, 
are  without  attention. 
11 — Not  more  than  one-third  of  the  workers  carry  any  form  of 
insurance  protection  against  sickness.  One-half  to  three- 
fourths  of  this  existing  sickness  insurance  is  carried 
through  the  sick  benefit  funds  of  the  lodges  and  fraternals. 
In  most  of  these,  sickness  insurance  is  secondary  to  life 
insurance.  As  a  rule,  no  medical  benefits  are  given,  and 
the  cash  benefit  is  but  fS.OO  a  week  for  thirteen  weeks  in 
any  single  year,  payable  only  after  a  man  has  been  ill  more 
than  two  weeks. 
Trade  union  funds  rarely  afford  better  protection.  Com- 
mercial health  insurance  is  costly  and  subject  to  many  re- 
strictive rules.  Establishment  funds  afford  better  protec- 
tion but  are  relatively  few  in  number  and  exist  only  among 
progressive  employers  where  health  hazards  are  often  re- 
duced to  the  minimum. 

THE  INFLUENCE  OF  WORKING  CONDITIONS  ON  HEALTH. 

I^ — Investigations  of  the  industries  of  Pennsylvania  have  shown 
that  "no  other  State  has  so  wide  a  variety  of  those  in- 
dustrial processes  which  carry  with  them  danger  to  the 
workers  either  because  of  poison  in  the  form  of  fumes, 
liquids,  or  dust,  or  because  of  mechanically  irritating  dusts 
which  injure  the  throat  and  lungs." 
II — Seventy-nine  per  cent,  of  all  the  deaths  of  persons  of  work- 
ing age  in  1916  were  from  diseases  whose  connection  with 
"important  Pennsylvania  industries  has  been  established." 
Death  rates  among  persons  of  working  age  in  Pennsylvania 
from  degenerative  diseases  due  in  large  measure  to  certain 
kinds  of  occupation  are  steadily  increasing. 

SICKNESS  PREVENTION. 

I — Fully  one  half  of  existing  sickness  could  be  eliminated  if 
proper  preventive  measure  were  taken. 
11^ — At  present  from  70  to  75  per  cent,  of  the  school  children  in 
Pennsylvania  are  physically  defective,  and  for  the  most  part 
the  defects  are  correctable  if  treated  in  time. 
Ill — A  large  number  of  communities  in  the  State  have  no-  active 
health  work,  much  less  an  adequate  appropriation  for 
health  activities. 


35 

IV — Nothing  so  stimulates  preventive  effort  as  definite  responsi- 
bility for  the  losses  entailed.  Preventive  measures  proved 
inadequate  to  meet  the  problems  of  industrial  accidents  un- 
til stimulated  hy  the  enactment  of  the  Workmen's  Compen- 
sation Law.  This  form  of  social  insurance  has  steadily  re- 
duced the  number  of  accidents  and  the  appeals  to  charity 
from  families  affected  and  has  proved  practical  in  adminis- 
tration. 
Our  own  and  other  investigations  prove  that  the  responsibility 
for  illness  rests  on  three  groups:  the  community,  industry 
and  the  individual.  At  present  these  three  groups  are  meet- 
ing the  losses  from  illness  in  wholly  unequal  shares;  the 
burden  on  the  individual  is  often  disastrous  and  out  of  pro- 
portion to  his  individual  responsibility,  ^ome  means  of 
just  distribution  of  this  burden  should  be  found.  There  is 
in  Pennsylvania  today  urgent  need  for  a  program  of  health 
measures  which  will  (a)  Provide  for  the  efficient  care  of 
employees  and  their  families  when  actually  ill,  and  (b)  In- 
stitute preventive  measures  which  will  in  so  far  as  it  is  pos- 
sible, prevent  illness  and  increase  the  opportunity  for  health 
and  vigor  in  the  citizenship  of  the  State. 


86 


KECOMMENDATIONS. 

Since  investigation  has  shown  that  sickness  among  wage  earners 
in  Pennsylvania  presents  a  serious  problem  of  vital  importance  not 
only  to  employees,  but  to  industry  and  to  the  State,  your  Committee 
recommends: 

1 — A  careful  study  of  possible  remedial  legislation  covering  the  fol- 
lowing points : 

a — Such  adequate  medical  care  for  employees  and  their 
families  during  sickness  as  will  materially  improve 
health  conditions,  by  reducing  the  frequency,  duration 
and  severity  of  illness  and  thus  decrease  time-loss  to  in- 
di'stry,  and  prevent  much  needless  suffering. 

b — A  means  of  meeting  the  wage-loss  ordinarily  suffered  by 
emploj^ees  during  pex'iods  of  illness  by  methods  which 
will  apportion  fairly  the  economic  burden  between  the 
three  elements  responsible — ^the  individual,  industry  and 
the  State. 

c — A  method  for  stimulating  State-wide  interest  and  active 
work  in  sickness  prevention. 

2 — A  special  study  of  proposed  and  existing  systems  of  health  in- 
surance in  this  and  other  countries,  with  special  attention  to 
problems  concerning  constitutionality  and  the  administration 
of  medical  benefits. 

3 — That  these  studies  be  under  the  direction  of  a  Commission  on 
which  the  medical,  nursing  and  legal  professions,  organized 
employers  and  organized  employees  shall  be  represented. 


i'AilT  1  — fefiCTiON  ii.— TABLE  I.— Leading  Occupations  bf  Pennsylvania  Wage 

Earners. 

(M6re  than  10,000  Persons  Employed]!. 


Occupation. 


Agriculture, 


Extraction    of   minerals, 


Building    trades, 
Shipbuilding,   ___ 


Iron,    and    steel,    steel    works    and    rolling 

mills.    

Foundries',  macbine-shop  products,  

Oars  and  construction  and  repair  by  steam 

railways,    

SSlli  goods,  

Hosiery  and  knit  goods,   __. 

Tobacco.    


Printing   and  publishing,   

Woolen  goods,  

Glass,  i 

Lumber,   „. 

Men's  clothing  and  shirts.  

Brick,  tile,  pottery,  clay  products,  

Women's  clothing.  

Bread  and  bakery  products,  

Electrical  machinery,  apparatus,  supplies. 

Cotton  goods.  

Boots  and  shoes,  

Leather  goods,  

Chemicals  and  allied  products,  

Liquors  and  beverages,  -^ 

Paper  and  paper  products, 

Laundries.  


Transportation, 
Trade,    


Number  ol 

Wage- 
Earners. 


(Including 

larm 

owners) 

336.615 

(mainly  hard 

and  soft 

coal) 

49,302 

100,000 


131.955 
91.820 

54.729 

*t44,755 

t*41,lS0 

*31,298 

•26,900 

»t24,461 

t23.606 

21,297 

•21.126 

18,976 

•17,217 

•15,157 

14,866 

•tl4,640 

*tl3,414 

11,988 

37,880 

9.405 

•17.979 

9,538 

238.841 
•307,371 


Source  of  Infdrmatlori. 


U.  S.  Census  of  Occupation*.  1810. 


Pa.   Department  of  Labor  and  In- 
dustry,   Production  Report,   1916. 


Pa.  Department  of  Labor  and  In- 
dustry.   Production   Report,    1916. 

Henry  R.  Saeger,  Secretary  Ship- 
building Labor  Adjustment  Board, 
1918. 

U.  S.  Census  of  Manufactures,  1914. 

U.  S.  Census  of  Manufactures,  1914. 

U.  S.  Census  of  Manufactures,  1914. 

U.S.  Census  of  Manufacturea,  1914. 

U.  S.  Census  of  Manufactures,  1914. 

Pa.  Department  of  Labor  and  In- 
dustry.   Production   Report,    1916. 

Pa.  Department  of  Labor  and  In- 
dustry.   Production  Report,    1914. 

Pa.  Department  of  Labor  and  In- 
dustry,   Production  Report.    1914. 

Pa.  Department  of  Labor  and  In- 
dustry,   Production  Report.    1914. 

Pa.  Department  of  Labor  and  In- 
dustry,   Production  Report,    1914. 

Pa.  Department  of  Labor  and  In- 
dustry,   Production  Report.    1914. 

Pa.  Department  of  Labor  and  In- 
dustry,   Production  Report.    1914. 

Pa.  Department  of  Labor  and  In- 
dustry,   Production  Report,    1914. 

Pa.  Department  of  Labor  and  In- 
dustry,   Production    Report,   1914. 

Pa.  Department  of  Labor  and  In- 
dustry,   Production   Report,   1914. 

Pa.  Department  of  Labor  and  In- 
dustry,   Production    Report,   1914. 

Pa.  Department  of  Labor  and  In- 
dustry,   Production   Report,   1914. 

Pa.  Department  of  Labor  and  In- 
dustry,   Production   Report,   1914. 

Pa.  Department  of  Labor  and  In- 
dustry.   Production   Report,    1916. 

Pa.  Department  of  Labor  and  In- 
dustry.   Production   Report,    1916. 

Pa.  Department  of  Labor  and  In- 
dustry,  Production   Report,   1914. 

Pa.  Deifartment  of  Labor  and  In- 
dustry,   Production   Report,   1916. 

U.   S.    Census  of  Occupation.  1910. 

U.   S.    Census  of  Occupation,  1910. 


•Large  proportion  of  females  employed. 

,t Large  number  of  children  under  16  years  employed. 


38 


l»ART  I.  -SECTION  11.— TABLE  J 1.— Number  and  Percentage  of  Pereoiis  10 
Years  of  Age  and  Over  Gainfully  Employed,  1910,  in  Pennsylvania,  Philadel- 
phia,   and  Pittsburgh   by   Principal   Occupational   Groups. 


Pennsylv 

ania. 

Philadelphia. 

Pittsburgh. 

Occupation. 

Number 
Employed. 

Per  cent. 

Number 
Employed. 

Per  cent. 

Number 
Employed. 

Per  cent. 

Total  employed,         -    - 

3,130,681 

100 

711,169 

100 

233.637 

100 

Agriculture 

362,123 
327,670 

607,079 
294,752 
172,498 
30,309 
131,036 
169.865 
301,383 
734,166 

11.6 
10.4 

19.3 
9.3 
5.5 
.96 
4.2 
5.4 
9.6 

23.1 

5,794 
1,332 

260,438 
99,113 
44,496 
11,477 
34,779 
62,487 
95,919 
95,334 

.81 
.18 

36.7 
13.9 
5.2 
1.6 
4.8 
8.7 
13.4 
13.3 

962 
840 

22.000 
31,559 
15.065 
3,453 
11,266 
23,864 
32,493 
92,130 

.41 

Extraction  of  minerals, 

Manufacturing  and  mechani- 
cal           _                

.35 
9.4 

Trade.    .  _    

13.5 

Transportation              

6.4 

Public  service.  

1.04 
4.5 

Clerical.    _    __.      —       

10.2 

Domestic 'and  personal, 

Laborer.   

13.9 
39.4 

39 


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PART  II. 
SECTION  I. 

The  Nature  and  Extent  of  .the  Sickness  Problem. 


(41) 


(42) 


43 


PART  II. 
SECTION  I. 

The  Nature  and  Extent  of  the  Sickness  Problem. 


No  part  of  the  United  States  has  as  yet  established  adequate  ma- 
chinery for  keeping  complete  sickness  statistics.  Pennsylvania  is 
no  exception  to  the  rule.  Our  information  then,  must  be  based  on 
more  or  less  fragmentary  material,  covering  certain  selected  groups, 
from  which  conclusions  can  be  drawn,  and  averages  taken. 

Averages  and  rates  tell  little  of  the  human  story. 

The  real  nature  and  extent  of  the  sickness  problem  among  em- 
ployees and  their  families  is  most  clearly  brought  out  by  studies  of 
conditions  among  groups  of  people  for  a  considerable  period.  For 
this  reason  we  have  summarized  briefly  the  results  of  three  studies 
giving  the  sickness  experience  of  three  different  groups  for  a  year. 
In  this  way  it  is  possible  to  see  how  sickness  really  affects  the  com- 
munity, and  to  place  it  in  its  natural  human  relations. 

The  first  study  is  of  a  typical  wage  earning  group  in  a  census 
enumeration  district  of  an  industrial  section  of  Philadelphia;  the 
second  covers  a  group  seeking  medical  care  from  the  Philadelphia 
Visiting  Nurse  Society;  the  third  is  a  study  of  a  group  of  working 
women.  The  sickness  experience  of  a  dependent  group  is  discussed 
in  Section  II. 

THE  KENSINGTON  SURVEY.i 

The  Kensington  Survey  was  a  door-to-door  investigation  made  for 
the  Commission  by  the  Pennsjdvania  School  for  Social  Service.  The 
area  of  the  survey  was  chosen  because  it  forms  part  of  the  industrial 
district  of  Kensington,  because  of  the  presence  therein  of  numerous 
manufacturing  establishments  engaged  in  the  production  of  a  variety 
of  goods,  and  also  because  of  its  proximity  to  the  Cramp  Shipbuild- 
ing Yards  and  the  ease  of  access  to  the  center  of  the  city,  thus  assur-' 
ing  a  diversity  of  industrial  and  commercial  employment.  From  a 
study  of  the  1910  census  figures  for  this  area  it  was  noted  that  various 
nationalities  would  be  found  and  that  the  home  life  would  be  typical 
of  the  working  population  of  the  State.  The  district  was  chosen  only 
after  representatives  of  the  School  had  not  only  studied  the  city  atlas 
for  the  types  of  buildings,  but  had  made  a  thorough  canvass  in  the  dis- 
trict itself  so  as  to  assure  the  School  that  the  population  was  a  normal 
working  group. 

Owing  to  the  care  with  which  this  district  was  chosen,  there  is  rea- 
son to  feel  that  a  fairly  typical  group  of  families  of  industrial  wage- 
earners  was  selected.     There  were  743  families,  including  3,198  in- 


(i)See  Table  II  at  end  of  this  Bection. 


44 

dividuals.  The  district  presented  some  eight  to  ten  nationalities,  but 
77.9  per  cent,  were  native  born  Americans.  The  highest  percentage  of 
foreign-born  were,  in  the  order  named,  Germans,  Austrians,  Irish  and 
Russians. 

That  the  group  was  in  no  way  a  dependent  group,  or  the  district  a 
"slum"  district,  is  witnessed  by  the  thrift  of  these  families — 189  of 
them  owned  their  own  homes,  and  626,  or  88  per  cent.,  had  purchased 
Liberty  Bonds.  The  house  rent  in  over  80  per  cent,  of  the  rental  cases 
was  between  ^10.00  and  |20.00. 

While  the  average  size  of  the  families  was  only  4.3  persons,  it  is 
noteworthy  that  the  number  of  wage-earners  averaged  1.94  per  family. 
In  sixty-three  cases,  the  mother  of  the  family  was  at  work  as  well  as 
the  father,  and  in  another  seventy  cases,  a  working  woman  was  the 
"head  of  the  house."  Eight  per  cent,  of  the  families  were  in  re- 
ceipt of  weekly  incomes  of  less  than  |15.00  and  47  per  cent,  more  had 
between  |15.00  and  |30.00,  making  more  than  half — 55  per  cent. — in 
receipt  of  weekly  incomes  of  |30.00,  or  less.  The  largest  single  group 
received  between  f20.()0  and  i||>25.00.  As  there  was  an  average  of  })rac- 
tically  two  wage  earners^per  family,  this  does  not  indicate  an  espe- 
cially high  wage-rate  for  individual  w^age-earners.  The  amount  of 
the  individual's  wage-loss  from  illness,  in  cases  where  this  could  be 
learned,  averaged  in  fact  just  about  f2.00  a  day. 

Nearly  half  of  the  wage-earners  were  employed  in  "manufacturing 
and  mechanical"  occupations;  that  is  to  say,  factory  work  and  hand 
trades.  The  next  largest  group  was  "trade,"  with  18  per  cent.,  and 
the  third,  "domestic  and  personal  service "  accounted  for  11.5  per 
cent.,  while  "professional  service"  accounted  for  but  1.4  of  the  num- 
ber, indicating  an  industrial  group ;  "laborers"  were  only  7.3  per  cent, 
of  the  total,  showing  that  the  group  was  above  the  average  for  in- 
dustrial employees. 

Undoubtedly,  in  going  over  a  year's  illness  experience,  many  minor 
ailments  were  ignored,  yet  only  12.4  per  cent,  of  the  734  families 
about  w^hom  these  facts  could  be  obtained  had  had  no  sickness  during 
the  year.  One  case  of  illness  was  reported  in  179  families,  two  cases 
in  173,  three  or  four  in  162,  and  five  or  more  in  126.  Twenty-six 
families  reported  ten  or  more  cases  of  illness.  Of  the  1,994  cases 
reported,  a  comparatively  high  proportion,  42.5  per  cent,  were  those 
of  wage-earners,  and  66  per  cent,  of  them  were  illnesses  either  of  wage- 
earners  or  of  housekeepers,  thus  causing  a  serious  wage  or  house- 
keeping loss.  In  527  instances  illness  of  the  principal  wage  earner 
was  reported,  319  cases  of  illness  of  other  wage-earners,  466  cases 
of  illness  of  the  housewife,  and  only  677  cases  of  illness  of  other  mem- 
bers of  the  family. 

In  the  1,472  cases  where  accurate  information  on  duration  was  ob- 
tained, 57.6  per  cent,  lasted  four  weeks  or  under;  the  largest  single 
number  falling  between  one  and  two  weeks,  when  351  cases  were  re- 


45 

corded.  Those  lasting  from  one  to  three  months  comprised  19.2  per 
cent.,  and  another  12.1  per  cent,  lasted  more  than  a  year.  When  over 
4.2  per  cent,  of  the  illness  registered  lasted  more  than  four  weeks  we 
begin  to  realize  how  disastrously  illness  may  affect  the  families  in  a 
group  such  as  this.  The  average  days  lost  from  work  on  account  of 
sickness  among  the  421  cases  of  wage-earners'  illness  causing  loss  of 
time  was  thirty-eight.  Three  hundred  and  sixty-seven  of  these  work- 
ers had  a  wage  loss  of  |28,S23.  or  an  approximate  average  of  |79.00 
for  each  case.  In  addition  to  the  loss  of  wages,  the  families  had  to 
bear  the  cost  of  medical  care.  Eighty-five  of  these  illnesses  were 
treated  free,  144  had  only  home  treatment  or  patent  medicines,  and 
no  treatment  whatever  was  recorded  for  an  additional  154  cases.  A 
private  doctor  was  most  often  consulted,  and  eighty-five  cases  had 
had  hospital  treatement.  The  families  for  the  most  part  met  the 
expenses  of  illness  through  their  own  resources.  The  employers 
helped  by  contributing  wages  or  paying  for  medical  care  in  a  little 
over  one  per  cent,  of  the  cases  of  sick  wage-earners.  In  99  per  cent, 
of  the  wage-earners'  illnesses  and  in  all  cases^f  the  illness  of  de- 
pendents, industry  assumed  no  responsibility. 

X  Seventy-seven  per  cent,  of  the  3,198  individuals  covered  had  pro- 
tected themselves  against  a  pauper's  burial  and  were  carrying  indus- 
trial life  insurance  policies  for  small  amounts ;  17  per  cent,  had  some 
form  of  "sickness  and  death"  insurance.  Thirty-four  per  cent,  of 
the  wage  earners  were  insured  in  this  way,  carrying  the  insurance 
through  fraternal  organizations  in  almost  three-fourths  of  the  cases. 
Less  than  three  per  cent,  were  insured  against  sickness  in  commer- 
cial insurance  companies. 

This  general  lack  of  insurance  protection  against  sickness  is  not 
surprising.  The  average  family  of  four  or  more,  with  a  weekly  in- 
come of  130.00  or  less  will  risk  the  somewhat  uncertain  chance  of 
sickness,  rather  than  pay  the  relatively  heavy  premiums  necessary  for 
adequate  protection.  Life  insurance  is  much  more  frequently  carried, 
for  death  is  a  certainty  and  the  desire  for  decent  burial  is  a  part  of 
the  worker's  self  respect.  And  yet,  among  these  Kensington  families, 
the  chance  of  avoiding  illness  was  very  poor — less  than  thirteen  in  a 
hundred  families  escaped  at  least  one  case  during  the  year,  and  some 
had  to  meet  the^  emergency  many  times. 

VISITING  NURSE  SOCIETY  STUDY. 
The  Staff  of  the  Visiting  Nurse  Society  of  Philadelphia  gathered, 
for  the  Commission,  data  covering  a  year's  sickness  experience  in  500 
of  the  families  to  which  they  were  called  during  July,  1918.  No  at- 
tempt was  made  to  confine  the  study  to  any  particular  kind  of  family ; 
they  were  choseil  consecutively,  and  the  result  was  an  ordinarily  self 
supporting  industrial  group,  more  than  half  of  whom  had  been  forced 
by  sickness  to  appeal  for  nursing  care  which  was  wholly  or  partially 


4G 

free.  The  500  families  visited,  about  one-fourth  of  whom  were  col- 
ored, contained  2,588  individuals,  or  an  average  of  five  per  family,  al- 
though 1,420,  or  more  than  half  the  total  number  of  persons  in  the 
group,  belonged  to  families  of  six  or  more  members.  More  than  half 
the  families  were  Americans  by  birth;  Italians,  Russians  and  Irish 
made  up  about  a  third ;  and  the  others  were  Austrians,  Germans,  Eng- 
lish and  Polish. 

There  is  nothing  particularly  striking  in  the  economic  history  of 
these  families,  compared  with  that  of  other  wage-earning  groups  of 
our  population.  Only  five  families  had  no  wage  earners.  Of  the  691 
wage  earners  in  the  group,  509  were  heads  of  families,  forty-five  were 
housekeepers  who  went  out  to  work,  and  128  were  other  members  of 
tlie  family.  Nine  of  these  were  under  sixteen  years  of  age.  Only 
one  wage-earner  was  found  in  each  of  355,  or  70.8  per  cent,  of  the 
families,  containing  more  than  half  the  total  number  of  individuals, 
while  only  forty-two  families  had  more  than  two  wage-earners.  More 
than  69  per  cent,  of  these  w^orkers  were  described  as  ^'steady,"  the 
others  being  ^'seasonal"  or  "casual,'^  in  many  instances  because  of  the 
nature  of  their  occupations.  Of  the  615  wage-earners  whose  occupa- 
tions were  known,  243,  or  36  per  cent,  were  engaged  in  manufactur- 
ing and  mechanical  trades,  and  130,  or  20.5  per  cent,  in  transporta- 
tion and  trade,  leaving  only  17.7  per  cent,  as  laborers  and  13.1  per 
cent,  in  domestic  and  personal  service.  Of  these  last  41  per  cent, 
were  the  working  housekeepers. 

The  incomes  reported  by  these  families  tell  a  story  strangely  at 
variance  with  the  popular  rumors  of  wealth  brought  by  the  war  to 
the  working  man.  Of  the  438  families  whose  incomes  were  known, 
with  an  average  membership  of  more  than  five,  one-third  had  incomes 
of  less  than  |20.00  per  week,  and  353  families,  or  80.6  per  cent.,  con- 
taining more  than  77  per  cent,  of  the  total  number  of  individuals, 
had  less  than  |30.00  per  week.  Only  eighty-five  families,  or  19.4  per 
cent.,  had  |30.00  or  over.  The  largest  single  group,  127,  or  28.9  per 
cent.,  containing  about  28  per  cent,  of  the  total  number  of  persons, 
had  between  |20.00  and  |;25.00  per  week,  in  13  per  cent,  of  the 
households,  the  incomes  had  been  augmented  by  lodgers,  ranging 
in  number  from  one  to  nine. 

In  spite  of  the  size  of  their  incomes,  238  families  had  been  able  to 
accumulate  small  savings ;  but  it  has  been  only  too  often  demonstrated 
that  under  present  living  conditions,  saving  by  families  of  five  or  six 
members  on  less  than  |30.00  per  week  usually  means  reducing  the 
allowance  for  food,  clothing,  rent  and  recreation  below  the  safety 
point. 

All  cases  of  illness  which  had  occurred  during  the  preceding  year 
were  recorded,  exclusive  of  the  illness  for  which  the  nurse  had  been 
called  at  the  time  of  the  survey.  In  addition,  all  cases  of  chronic 
illness  were  included,  many  of  which  were  of  more  than  a  year's 


duration.  There  were  418  families,  or  more  than  83  per  cent.,  who 
had  had  at  least  one  case  of  illness  during  the  year,  making  a  total 
of  1,043  cases.  Each  of  375,  or  75  per  cent,  of  the  families  reported 
two  or  more  cases  each,  while  fifty  families  reported  five  or  more 
cases.  In  561,  or  53.7  per  cent,  of  the  cases,  it  was  either  a  wage 
earner  or  a  housekeejjer  who  was  ill,  in  200  cases  it  was  the  principal 
wage  earner,  and  in  31(5  the  housekeeper.  Typhoid  fever,  tuber- 
culosis, respiratory  diseases  including  pneumonia,  and  digestive  di- 
seases, accounted  for  290,  or  27.8  per  cent,  of  the  cases,  children's  di- 
seases for  164  cases,  diseases  of  the  puerperal  state  for  89,  and  acci- 
dents for  forty-eight. 

During  the  year,  234  wage-earners,  or  33.8  per  cent,  of  the  total 
number,  were  ill ;  208,  or  89  per  cent,  of  these,  or  30  per  cent,  of  the 
total  number  of  wage-earners,  lost  time  from  work  because  of  sick- 
ness. The  total  length  of  time  lost,  including  that  lost  by  those  suf- 
fering from  chronic  illness,  was  known  in  the  cases  of  201  workers, 
and  amounted  to  13  528  working  days,  or  an  average  of  more  than 
sixty-seven  days  for  each  of  the  201,  or  more  than  nineteen  days  for 
each  of  the  691  wage-earners  in  the  study. 

Of  this  time,  which  is  equivalent  to  more  than  forty-five  working 
years,  4,590  days,  or  almost  one-third,  were  lost  by  nine  men.^  Five 
men  had  lost  an  average  of  more  than  525  consecutive  days  each,  and 
one  man  hal  been  at  home  sick  for  720  days.  He  was  suffering  from 
tuberculosis,  a  curable  disease  if  treated  in  its  early  stages,  and  be- 
cause of  his  illness  his  two  daughters,  sixteen  and  seventeen  years  of 
age  and  both  tubercular,  were  forced  to  work  regularly,  earning  to- 
gether about  129.00  per  week  for  the  support  of  the  family  of  five. 

Only  forty  of  these  201  workers  lost  less  than  two  weeks  time  be- 
cause of  sickness,  while  ninety-three,  or  46  per  cent,  lost  from  one  to 
six  months  each.  Of  these  last,  only  nineteen  belonged  to  families 
whose  incomes  were  as  much  as  |30.00  per  week. 

Of  the  total  time  lost,  9,577  days  were  lost  by  families  whose  in- 
comes were  known,  and  of  this  loss  more  than  half  was  suffered  by 
100  families  with  incomes  of  less  than  |25.00  per  week.  The  average 
loss  for  these  families  was  more  than  ninety-five  working  days  each. 

In  addition  to  the  suffering  caused  by  suspension  of  the  family  in- 
come, illness  in  many  cases  made  necessary  expenditures  for  medical 
care  for  which  the  families  were  entirely  unprepared.  Medical  and 
dental  care  were  received  by  412  families.  This  care  was  obtained 
free  in  twenty-two  cases,  and  the  cost  was  unknown  in  twenty-seven 
others.  The  363  families  whose  expenditures  were  known  spent  $17,- 
102.29,  or  an  average  of  more  than  |47.00  each,  or  more  than  |34.00 
for  each  of  the  500  families  in  the  whole  group.  The  same  uneyen- 
ness  of  distribution  is  seen  in  this  expense  as  in  the  loss  of  time. 


(')See  Table  III  at  end  of  section. 

4 


48 

Fifty-three  per  cent,  of  the  entire  cost,  or  |9,193.50,  was  borne  by 
fifty  families,  less  than  one-seventh  of  the  entire  number.  Of  these 
fifty  families,  whose  expenses  ranged  from  flOO.OO  to  $416.00  each,  the 
incomes  of  twenty-six  were  less  than  |30.00,  and  of  fifteen  were  less 
than  $20.00  per  week.  Two  families  with  incomes  of  |20.00  per  week 
had  doctor's  biUs  of  $202.00  and  $400.00  resspectively.  More  than  47 
per  cent,  of  the  families  spent  over  $25.00  each,  while  only  29  per 
cent,  escaped  with  less  than  $l6.00. 

Sixteen  families  spent  more  than  $200.00  each,  and  of  these,  ten 
spent  more  than  $300.00  each;  while  thirteen  families  had  medical 
and  dental  expenditures  amounting  to  more  than  20  per  cent,  of  their 
total  incomes. 

As  in  the  Kensington  Survey  the  means  of  meeting  these  burdens 
were  left  for  the  worker  and  his  family  to  devise,  the  employer  help- 
ing in  only  three  per  cent,  of  the  cases.  In  about  a  third  of  the 
cases,  emergencies  were  met  by  reducing  the  usual  outlays  for  liv- 
ing expenses,  while  in  another  third  money  was  borrowed,  credit 
obtained  and  help  received  from  charity,  friends  and  relatives.  Sav- 
ings were  a  help  in  about  20  per  cent,  of  the  families.  The  amount 
of  health  insurance -carried  was  small;  only  seventeen  families  had 
complete  insurance  protection  and  eighty-five  were  partially  insured. 

Industrial  policies  of  the  Metropolitan  Life  Insurance  Company, 
entitling  the  holder  to  nursing  care,  were  held  by  199,  or  39.8  per 
cent,  of  the  families ;  thirty-seven  others,  or  7.4  per  cent,  were  classed 
as  "pay"  patients.  189,  or  37.8  per  cent.,  as  "part  pay,"  and  seventy- 
four,  or  14.8  per  cent,  as  "free." 

The  very  large  proportion  of  instances  in  which  an  attempt  was 
made  to  secure  medical  care  is  probably  due,  in  part,  to  the  fact  that 
so  many  of  the  families  carried  industrial  life  insurance  which  se- 
cured nursing  care  for  them  and  strongly  encouraged  medical  treat- 
ment. 

A  private  doctor  was  consulted  in  650,  or  64.3  per  cent,  of  the  1,038 
cases,  where  the  nature  of  treatment  was  known;  a  visiting  nurse 
was  used  in  130,  or  12  per  cent,  of  the  cases,  a  hospital  or  convalescent 
home  in  19  per  cent.,  and  no  medical  care  at  all,  or  medicine  only, 
in  17  per  cent. 

The  experience  of  these  families  brings  out  vividly  the  universal 
nature  of  the  sickness  risk,  and  the  severity  of  the  losses  of  time  and 
money  which  may  fall  on  the  whole  group,  but  which  are  sure  to  fall 
with  crushing  weight  on  a  certain  number,  regardless  of  individual 
responsibility  or  resources. 

When  wages  among  comparatively  skilled  workers  are  insuflftcient 
to  provide  even  the  necessities  for  comfortable,  healthful  living ;  when 
there  is  at  least  an  80  per  cent,  chance  that  some  one  in  each  family 
will  be  ill  every  year ;  when  in  at  least  30  per  cent,  of  the  families  ill- 


49 

ness  will  cut  off  the  family  income  and  necessitate  an  additional  ex- 
penditure for  medical  care,  frequently  amounting  to  a  large  part  of  a 
year's  wages,  it  is  apparent  that  industry  and  the  state,  both  in  part 
responsible,  must  share  with  the  individual  in  the  distribution  of  the 
sickness  risk. 

WORKING  WpMEN'S  RECORDS. 

In  August  and  September,  1918,  a  study  was  made  of  502  working 
women  who  were  members  of  the  Young  Women's  Christian  Asso- 
ciation Industrial  Clubs  in  twenty-two  different  cities  in  seventeen 
counties  of  Pennsylvania.  Because  of  the  time  of  year  in  which  the 
study  was  made,  it  was  impossible  to  obtain  records  for  a  larger  num- 
ber, but  all  club  members  who  could  be  reached  by  the  Secretaries 
were  included,  and  the  study  was  not  limited  to  a  special  occupation 
or  group. 

In  all  probability  these  girls  had  more  education  and  advantages 
tlian  many  other  working  women.  In  age,  35  per  cent,  of  them  were 
under  twenty,  45  per  cent,  between  twenty  and  twenty-five,  and  only 
six  per  cent,  were  over  thirty. 

Nine-tenths  of  them  were  Americans,  and  almost  three-fourths  were 
native-born  of  native-bom  parents.  Four-fifths  of  the  girls  were  liv- 
ing at  home,  with  their  families.  There  were  100  who  were  living  in- 
(lei)endently.  P^leven  of  these  100  contributed  to  the  support  of  their 
families,  as  well  as  supporting  themselves,  and  127  of  the  girls  who 
lived  at  home  were  giving  all,  or  part  of  their  earnings  towards  the 
family  budget.  More  than  a  third  of  the  368,  about  whom  this  fact 
was  known,  had  one  or  more  persons  wholly  dependent  on  their  earn- 
ings. Forty-eight  were  married  women,  more  than  half  of  whom 
had  dependents,  and  the  percentage  of  these  married  women  who 
had  others  wholly  dependent  upon  them  was  double  that  of  the  un- 
married women. 

Of  439  of  these  girls,  but  fifty-five  had  entered  work  for  the  first 
time  since  the  war.  Sixty-six  had  changed  the  type  of  work  they 
were  doing,  in  forty-eight  cases  because  of  the  possibility  of  making 
better  wages.  Over  70  per  cent,  had  continued  the  same  type  of  work 
which  they  had  been  doing  before  the  war;  and  of  these  62  per  cent, 
had  had  a  wage  increase. 

Comparative  wage  statistics  were  obtained  for  240  girls,  showing 
the  weekly  amount  received  in  1916  and  tliat  received  in  1918.  Even 
in  the  latter  year,  with  the  supposed  great  increase  in  wages,  89  per 
cent,  of  them  were  earning  less  than  |20.00  a  week.  In  1916,  99  per 
cent,  had  been  earning  less  than  this  amount,  the  wages  of  55  per 
cent,  being  under  .f  10.00;  in  1918  this  percentage  had  dropped  to  in- 
clude only  a  third ;  while  the  percentage  earning  between  flO.OO  and 
120.00  had  increased  from  44  to  55  per  cent. 


50 

The  following  table  shows  the  changes  in  the  numbers  in  the  dif- 
ferent wage  groups. 


Weekly  Wages. 

1916. 

1918. 

Under  ^.00,    .    .    

24 
65 
43 

46 
SO 
25 

4 
2 
1 

8 

&—  7.99,    —    

30 

S—  9  99                                                                        ___               _            _     ... 

43 

10—11  99'                                                  --    i _      t- 

59 

12—14  99              -      -     

44 

16_17,99,                      _.        .__     ___      ___      . .      

i^ 

18—19.99,    1 

14 

20—24  99 

21 

25  and  over,  



5 

It  was  found  that  in  243  cases,  168  had  liad  wage  increases,  seventy 
were  receiving  the  same  wage,  and  five  had  had  their  wages  decreased. 

More  than  half  of  the  girls — 56  per  cent. — were  doing  work  on  a 
time  basis.  The  piece  workers  were  apparently  somewhat  better 
paid,  for  while  only  forty-two  of  the  time  workers  were  receiving 
over  |15.00  a  week,  seventy-seven  of  the  piece  workers  were  earning 
over  this  amount.  A  large  proportion  of  both — 83  per  cent,  of  time 
workers  and  59  per  cent,  of  piece  workers — received  less  than  $15.00 
weekly. 

Over  60  per  cent,  of  the  girls  worked  in  factories,  of  these  a  large 
number  in  garment  and  textile  factories.  Forty-eight  girls  worked  in 
stores,  and  fqrty-three  in  offices,  thirty-five  did  housework,  and  the 
rest  were  scattered  in  various  other  occupations. 

But  154  of  these  502  girls  had  escaped  illness  expenditure  during 
1917.  Three  hundred  and  forty-eight,  or  over  69  per  cent,  had  suf- 
fered financial  loss  in  varying  degrees  because  of  accident  or  disease. 
The  type  of  care  and  the  cost  of  that  care  were  known  in  284  ai  the 
348  cases.  The  average  expenditure  was  $27.78  for  each  of  the  284 
girls,  or  |15.72  for  each  of  the  502  girls  in  the  group  studied.  This, 
however,  gives  no  idea  of  the  burden  imposed  upon  the  few  who  suf- 
fered severe  illness.  The  total  expenditure  for  the  284  girls  was  $7,- 
890.02.  Thirty-nine  per  cent,  of  this,  over  $3,000.00,  was  spent  by 
nine  per  cent,  (twenty-eight  persons)  of  the  group,  and  one-fourth  of 
this  total  expenditure  was  paid  out  by  only  ten  girls. 

A  doctor  was  called  in  by  199  of  the  girls,  medicine  was  bought  by 
139,  ten  girls  had  hospital  treatment,  and  three  had  nursing  care.  An 
unusually  large  proportion — ^256 — had  had  some  expenditure  for 
dental  care,  due  in  part,  no  doubt,  to  the  special  talks  which  the  Clubs 
have  had,  laying  emphasis  on  the  care  of  the  teeth.  Every  girl  who 
liad  had  some  expenditure  had  spent  more  than  |5.00.  The  largest 
number  spent  between  $20.00  and  $30.00. 

One  girl,  making  less  than  $5.00  a  week  in  a  factory,  was  trying  to 
pay  off  a  bill  of  $166.00.  Another,  earning  $5.00  a  week  at  house- 
work, had  been  ill  for  six  months,  had  had  two  operations,  and  was 


51 

confronted  with  a  bill  of  $685.00.  She  had  managed  to  pay  a  part  of 
this  with  some  money  she  had  saved,  and  was  paying  the  remainder 
on  the  installment  plan.  A  third  girl,  working  in  a  restaurant,  earn- 
ing 112.50  a  week-,  hurt  her  knee  and  was  obliged  to  be  away  from 
work  for  six  months  and  to  spend  over  a  hundred  dollars.  A  fourth 
girl,  a  cotton  winder,  earning  $14.00  a  week,  had  a  bill  of  $119.00  for 
weekly, treatments  of  her  nose  and  throat.  Three  of  these  girls  were 
living  away  from  home,  and  had  to  meet  these  bills  as  best  they  could. 
It  is  significant  that  two-thirds  of  the  twenty-eight  girls  who  had  ex- 
penditures of  over  $50,000  were  earning  less  than  $15.00  a  week. 

The  methods  used  to  finance  the  cost  of  sickness  were  known  in  383 
cases.  In  many  instances  more  than  one  method  was  used.  Savings 
were  used  almost  four  times  as  often  as  any  other  method — 210  times. 
The  girl's  family  helped  her  in  fifty-nine  cases.  In  forty  cases  she 
belonged  to  a  lodge,  which  was  of  some  assistance,  although  the 
benefits  were  too  small  to  be  of  great  help,  and  often  were  not  re- 
ceived. Eight  girls  carried  commercial  health  insurance.  In  only 
three  cases  were  wages  continued  while  the  girl  was  ill.  In  no  case 
did  a  girl  go  to  a  charitable  relief  agency  or  to  a  money  lender.  Only 
one  girl  had  a  "gift"  to  help  pay  her  doctor's  bill.  In  several  cases 
it  was  noted  that  the  doctor  made  special  rates. 

No  girl  who  must  live  on  $12.00  a  week  can  by  herself  save  enough 
to  meet  the  unusual  expenses  of  illness,  and  this,  too,  when  her  regular 
income  is  suspended.  Upon  the  health  of  the  woman  in  industry  de- 
pends not  only  her  efficiency  and  the  profit  of  her  employer,  but  the 
welfare  of  the  race  and  the  vigor  of  our  future  citizenship.  In  the 
face  of  these  obvious  truths,  it  cannot  be  questioned  that  some  method 
must  be  found  by  which  the  girl  worker  shall  no  longer  have  to  bear 
99  per  cent,  of  the  sickness  burden  alone,  but  that  the  industry  and 
the  community  to  which  her  well  being  is  essential,  and  upon  which 
rest  a  part  of  the  responsibility  for  illness,  shall  also  share  the  cost. 

EXTENT  OF  SICKNESS. 

In  studying  sickness  as  a  problem,  one  of  the  first  questions  to  be 
considered  is  its  extent.  How  many  people  are  sick  every  year  or 
every  day,  how  long  do  their  illnesss  last,  and  how  much  do  they 
lose  on  account  of  illness?  The  most  common  method  of  answering 
these  questions  and  the  one  which  will  first  be  used,  is  by  giving  the 
"average  sickness  rate"^  among  large  groups  of  people. 

The  facts  are  drawn  mainly  from  the  Kensington,  Philadelphia,  and 
Western  Pennsylvania  Surveys,  the  Sickness  and  Dependency  Study, 
and  the  establishment  fund  and  Workmen's  Circle  statistics. 


(1) Sickness  rates  are  usually  stated  as  follows: 

1.  Number   of  persons   per   1,000   of   the   group   or   population   under   consideration    disabled 

per  year. 

2.  Average  length,  of  disability  per  disabled   person. 

3.  Average  number  of  days    of    disability    per   year    per   person    included    in    group    or   pec- 

ulation under  consideration. 

4.  Number  of  persons  per  1,000  of  the  group  or  population  \mder  consideration  disabled  per 

day. 


52 

LIMITATIONS  OF  SURVEY  FIGURES. 

The  rates  of  sickness  deduced  from  sickness  surveys  must  not, 
of  course,  be  taken  as  anything  but  a  rough  index  of  the  actual 
amount  of  illness.  Aside  from  differences  in  racepsex  and  age  com- 
position of  the  population,  which  are  to  be  taken  into  account  in  all 
forms  of  social  statistics,  much  depends  upon  the  care  with  which 
the  figures  are  collected.  Other  things  being  equal,  nurses,  who  were 
the  enumerators  in  Philadelphia  Survey,  are  probably  able  to  secure 
more  complete  figures  than  lay  investigators.  Persons  who  have 
the  confidence  of  the  families  interviewed  naturally  obtain  better 
information  than  those  of  whom  they  feel  suspicious. 

The  season  of  the  survey  is  likely  to  have  a  decided  effect  on  the 
sickness  rate,  as  sickness  is  generally  more  prevalent  in  winter  and 
in  early  spring,  at  the  time  when  the  Western  Pennsylvania  Survey 
was  taken.  In  August  and  September,  the  season  of  the  Philadel- 
phia Survey,  sickness  is  usually  at  the  minimum. 

Even  the  definition  of  "sickness"  used,  varies  from  survey  to  sur- 
vey. For  instance,  only  "serious"  cases  of  sickenss  were  enumerated 
in  the  Western  Pennsylvania  Survey.  In  any  enumeration  of  the 
illnesses  occurring  during  a  long  period  such  as  the  illness  histories 
in  the  Kensington  Survey,  much  sickness,  especially  that  which  is 
trivial,  is  forgotten.  Serious  illnesses,  especially  those  of  wage- 
earners,  are  likely  to  be  remembered,  but  slighter  ailments  and  chil- 
dren's diseases  are  apt  to  be  passed  over. 

The  possibility  of  considerable  variation  in  sickness  rates  is  well 
illustrated  toy  three  sickness  surveys  made  in  Framingham,  Mass.,^  in 
the  spring  of  1917.  In  the  first,  special  care  was  used  to  secure  com- 
pleteness and  to  include  both  disabling  and  less  serious  illnesses. 
The  enumeration  was  made  by  nurses  and  insurance  agents.  The 
rate  found  was  6.2  per  cent,  for  ^1  sickness  and  3.8  per  cent,  for  per- 
sons unable  to  work.  But  by  adopting  the  definition  of  sickness  used 
in  the  Metropolitan  Life  Insurance  Company  surveys,  which  was 
said  to  be  "actual  complete  disability",  the  sickness  rate  fell  to  1.8 
per  cent.,  while  in  a  "patriotic  census"  taken  among  practically  the 
same  group  a  few  weeks  later,  a  sickness  rate  of  3.2  per  cent,  was 
reported. 

SICKNESS  RATES  IN  SICKNESS  SURVEYS. 

The  Philadelphia  Survey  as  has  already  been  explained,  included 
all  illnesses  existing  on  the  day  of  the  investigator's  visit.  Of  the 
12,019  persons  covered,  514  were  found  to  be  actually  ill  at  the  time 
of  the  survey.  This  indicates  an  average  daily  sickness  rate  of  4.28 
per  cent.  In  other  words,  approximately  forty-three  persons  in  every 
one  thousand  in  the  district  covered  by  the  survey  are  ill  every  day 


(^) Framingham  Community  Health  and  Tuberculosis  Demonstration  of  the  National  Tuberculosis 
Association.      "The  Sickness  Census,"  Framfngham  Monograph  No.   2,    Medical  Series  No.   1. 


53 

ill  the  year.  Of  these  cases,  liowever,  only  36.7  per  cent,  were 
''unable  to  work",  showing  that  on  this  basis  an  average  of  1.57  per 
cent,  or  sixteen  per  thousand  of  the  persons  visited  are  afflicted  each 
day  with  sickness  which  actually  disables  them.  The  Western 
Pennsylvania  Survey  on  the  other  hand,  included  only  "serious"  ill- 
nesses and  showed  a  daily  sickness  rate  of  1.96  per  cent.  Of  the 
sick  persons  found,  94  per  cent  were  "sick,  unable  to  work,"  indicat- 
ing that  an  average  of  1.87  per  cent,  or  approximately  nineteen  per- 
sons out  of  every  1,000  were  suffering  from  actually  disabling  illness 
every  day  in  the  year.  The  fact  that  the  Philadelphia  Survey  was 
made  in  August  and  September,  and  the  Western  Pennsylvania  Sur- 
vey in  March  would  easily  account  for  the  difference  in  the  amount 
of  sickness  found. 

In  the  Visiting  Nurse  Study  the  illnesses  existing  on  the  day  of 
the  visit  were  not  recorded,  and  it  was,  therefore,  impossible  to  secure 
the  daily  sickness  rate.  A  total  of  1,043  cases  of  illness  were  reported 
for  the  year  among  the  2,588  individuals  covered,  indicating  that 
of  this  group  40  per  cent,  suffered  illness  during  the  year. 

Some  interesting  calculations  are  suggested  by  the  survey  figures. 
The  average  daily  sickness  rates  which  we  have  quoted  seem  to  show 
that  in  the  district  covered  by  the  Philadelphia  Survey  each  person 
suffers  on  an  average  5.7  days  of  actually  disabling  sickness  each 
year,  and  that  the  corresponding  rate  in  the  Western  Pennsylvania 
group  is  6.8  days  per  person.^  If  we  accept  the  rates  of  1.57  per 
cent,  for  disabling  sickness  and  2.71  per  cent,  for  slighter  ailments 
established  by  this  study  as  a  fairly  complete  measure  of  sickness, 
an  average  of  140,000  persons  in  the  state  are  constantly  suffering 
from  severe,  and  245,000  more  from  lesser  illnesses,  making  a  total 
of  350,000  sick  persons  in  the  state  every  day  in  the  year;^  The 
average  number  of  days  of  disabling  sickness  of  adults  per  year 
is  probably  over  seven  and  the  average  number  of  days  lost  from 
work  is  about  six.^ 

These  figures  we  feel  are  undoubtedly  lower  than  those  which  more 
complete  investigations  would  yield.  Considering  the  mortality 
rates  in  Pennsylvania,  the  comparative  status  /  of  public  health 
appropriations  and  the  large  proportion  of  the  population  engaged 
in  industry,  the  days  loss  is  probably  much  higher.  The  United 
States  Public  Health  Service  estimates  that  an  average  of  3,000,000 
persons  are  ill  in  the  the  United  States  at  any  given  date,  and  that 
each  of  the  nation's  30,000,000  wage  earners  loses  an  average  of  nine 
working  days  each  year  because  of  sickness. 

SICKNESS  RATES  IN  ESTABLISHMENT  FUNDS. 
Sickness  rates,  which  are  to  a  certain  extent  inaccurate  may  be 
obtained  from  the  records  of  societies  paying  sick  benefits.     As  ^ 

(MSee  Table  IV  at  end  of  this  section. 

(2)  On  the  basis  of  1918  estimated  population. 


54 

rule  these  funds  have  a  "waiting  period''^  and  their  records  do  not 
take  into  account  illness  of  a  shorter  duration  than  that  period,  or 
that  portion  of  illness  cases  continuing  after  the  expiration  of  the 
benefit  period. 

Therefore,  only  benefit  funds  which  have  the  same  "waiting  period" 
have  comparable  sickness  rates.  Seventeen  of  the  twenty  Pennsyl- 
vania funds  studied  by  the  U.  S.  Bureau  df  Labor  Statistics,  having 
a  membership  of  07,000  persons,  had  the  same  seven  day  "waiting 
period."  The  figures  compiled  indicate  that  during  each  year  about 
1^0  per  cent,  of  the  members  of  these  funds  have  illnesses  for  which 
they  receive  sickness  benefit.^ 

The  Pennsylvania  Funds'^  closely  resemble  those  in  other  parts  of 
the  country  in  this  respect,  for  the  average  number  of  illness  cases 
per  100  members  in  all  the  funds  studied  is  twenty-six.  The  average 
number  of  illness  cases  in  the  "Workmen's  Sick  and  Death  Benefit 
Fund  of  America,"  covering  a  five-year  experience,  was  twenty-four 
per  100  members.  The  reports  of  the  Workmen's  Circle  for  the  year 
1916  shows  a  slightly  lower  rate,  twenty-three  cases  per  100  members 
per  year.*  A  disproportionate  number  of  its  members,  however,  are 
clerks  and  "business  men"  (probably  proprietors  of  small  retail 
stores.)  Persons  in  such  occupations  are  subject  to  the  health 
hazards  of  a  sedentary  life,  but  comparatively  little  exposed  to  the 
more  definite  occupational  poisonings  and  hazards. 

DURATION  OF  ILLNESS. 

Average  rates  of  illness  covering  persons  both  sick  and  well  indicate 
the  magnitude  of  the  sickness  problem  as  a  whole,  but  do  not  in  any 
way  show  the  burden  of  sickness  to  the  individual.  One  man  may  es- 
cape illness  altogether,  and  his  neighbor  lose  two  weeks  from  work, 
while  a  third  is  ill  six  months,  uses  up  his  savings  and  is  left  with  a 
burden  of  debt. 

Statistics  on  the  duration  of  illness  have  been  collected  from  two 
sources ;  Sickness  Purveys,  and  the  actual  records  of  Establishment 
and  Sick  Benefit  Funds. 

SICKNESS  SURVEY  FIGURES." 

The  Western  Pennsylvania  and  the  Philadelphia  Survey  figures 
would  seem  to  be  on  the  most  closely  comparable  basis,  as  both  cover 
only  diseases  existing  at  the  time  of  the  survey  and  duration  to  that 
date. 


(i)The  "waiting  period"  is  the  time  at  the  beginning  of  an  illness  before  benefits  are  paid. 

(2) See  Table  XIV  at  the  end  of  this  section. 

(3) Information  eoncerning  tAventy  Pennsylvania  "establishment  funds"  was  included  In  a  nation- 
wide investigation  of  such  funds  by  the  United  States  Bureaii  of  Labor  Statistics  In  1917. 
Through  the  kindness  of  Dr.  Royal  Meeker,  the  Chief  of  the  Bureau,  it  was  possible  for  the  Com- 
mission to  secure  this  material,  as  well  as  figures  en  the  "Workmen's  Circle"  a  national  mutual 
benefit   society  with    about   40,000  members,    in    advance   of  juiblication. 

(*)For  the  year  1916,  the  "Workmion's  Circle"  reported  6.9  per  cent,  of  its  membership  111 
in  the  first  quarter;  5.9  per  cent.  In  the  .second;  5.2  per  cent,  in  the  third;  and  5  per  cent,  in  the 
fourth,  or  a  total,  disregarding  illnesses  of  more  than  one  quarter,  of  twenty-three  cases  per  100 
members,  for  the  year. 

(')The  Western  Pennsylvania  figures  do  not  include  negroes, 


55 

But  in  the  Philadelphia  Survey  special  effort  was  made  to  ferret  out 
chronic  illness,  while  the  Western  Pennsylvania  Survey  dealt  only 
with  "serious  illness."  The  results  for  Philadelphia  are  startling. 
Twenty-eight  per  cent,  of  the  cases  in  this  study  were  chronic,  last- 
ing three  years  or  more,  and  an  additional  25  per  cent,  lasted  longer 
than  one  year.  In  other  words,  over  half  the  cases  where  duration 
was  known  lasted  more  than  a  year,  bearing  out  the  conclusion  that 
illness  among  employees  is  too  often  untreated  in  its  early  stages 
and  that  many  half -sick  men  continue  at  work.  Even  the  25  per  cent, 
of  illness  of  more  than  a  year's  duration  found  in  the  Western  Penn- 
sjdvania  Survey  is  significant  of  a  situation  which  demands  attention.^ 

In  the  latter  study  56  per  cent,  lasted  longer  than  a  month,  while 
this  figure  is  raised  to  76  per  cent,  in  the  Philadelphia  Survey.  In 
both  surveys,  the  number  of  very  short  illnesses,  of  less  than  one 
week's  duration,  was  relatively  insignificant. 

In  the  Sickness  and  Dependency  Study,  it  was  possible  to  tabulate 
the  average  length  of  the  386  cases  of  illness  which  had  ended  at  the 
time  of  the  survey.  Seventy-five  per  cent,  of  these  lasted  longer  than 
one  month,  the  largest  proportion,  or  22.2  per  cent.,  falling  in  the  one- 
to-three  month  group,  while  in  the  Kensington  Survey,  42.3  per  cent, 
of  the  illnesses  lasted  longer  than  a  month.  In  this  survey,  421  cases 
of  illness  of  wage-earners  were  reported  with  a  total  duration  of  16,- 
090  days,  or  more  than  thirty-eight  days  per  case.  In  these  two 
studies  a  small  percentage  of  long  illnesses  of  over  a  year's  duration 
was  found.  But  this  is  probably  due  to  the  relative  incompleteness 
of  these  studies  as  compared  to  the  Philadelphia  and  Western  Penn- 
sylvania Surveys. 

ESTABLISHMENT  AND  SICK  BENEFIT  FUND  FIGURES. 

A  study  of  twelve  Well  organized  establishment  funds,  four  pei* 
cent,  of  which  were  in  Pennsylvania,  was  made  during  the  summer 
and  fall  of  1918  by  the  Connecticut,  Ohio,  Illinois  and  Pennsylvania 
Health  Insurance  Commissions  with  the  help  of  Mr.  Boris  Emmet  of 
the  United  States  Bureau  of  Labor  Statistics.  The  results  of  this 
study  were  tabulated  by  the  Ohio  Commission  in  ten  groupings.  The 
benefit  associations  selected  for  study  include  employees  in  the  fol- 
lowing occupations:  railroad  transportation,  manufacture  of  iron 
and  steel  products,  textiles,  steel  mill,  general  foundry  work  and  let- 
ter carriers. 

The  most  important  facts  to  be  gathered  from  this  study  relate  to 
the  duration  of  the  illnesses  for  which  benefit  had  been  paid.  As 
most  of  the  funds  had  a  seven  day  "waiting  period,"  only  cases  of 
more  than  eight  days'  duration  were  used  in  the  combined  experience 
tables.  Because  of  differences  in  administration  of  benefits  and 
hazards  of  the  several  occupations  represented,  the  proportions  of 
cases  of  long  and  short  duration  vary  widely  in  the  different  funds. 

(MSee  Table  X  at  end  of  this  sertion. 


56 

For  instance,  55.73  per  cent,  of  the  sickness  in  Fund  No.  1  lasted  less 
than  two  weeks,  while  in  Fund  No.  10  only  IG.l  per  cent,  was  ol' 
this  duration.  In  the  "over-six-months''  group,  Fund  No.  1  had  1.39 
per  cent,  of  its  cases,  while  Fund  No.  10  had  5.24  per  cent. 

Taking  the  combined  experience  of  these  funds,  however,  it  was 
found  that  34.56  per  cent,  of  the  cases  lasted  less  than  two  weeks; 
34.68  lasted  more  than  a  month,  and  3.26  per  cent,  more  than  six 
months.^ 

The  illnesses  of  females  seem  to  be  of  longer  duration  than  those 
of  males,  according  to  the  experience  of  one  fund  having  both  men 
and  women  in  its  membership ;  for  while  40.98  per  cent,  of  the  illness 
cases  among  the  men  were  of  less  than  two  weeks'  duration,  only  27.73 
per  cent,  of  the  women's  illnesses  were  in  that  group.  Thirty  and 
six  one-hundredths  per  cent,  of  the  men's  illnesses  and  42.65  per  cent, 
of  the  women's,  lasted  longer  than  one  month,  raising  the  percentage 
of  illnesses  for  the  fund,  of  more  than  one  month's  duration,  to  37.02 
per  cent.,  or  slightly  higher  than  the  combined  experience  of  the 
twelve  funds.^  We  cannot  be  sure,  however,  that  this  higher  rare 
is  due  to  the  inclusion  of  women,  because  in  the  United  States  Letter 
Carriers  'Association,  one  of  the  twelve  funds  studied,  42.9  per  cent, 
of  the  illnesses  lasted  more  than  one  month. 

One  of  the  funds  studied  by  the  Pennsylvania  Commission  was  the 
Pennsylvania  Railroad  (East)  Voluntary  relief  Department.  Al- 
though, as  is  explained  in  the  section  on  "Losses  to  Industry  because 
of  Sickness  among  Employees,"  this  stud}^  is  not  complete,  64,849 
of  the  completed  cases  of  illnesses  and  non-industrial  accidents  which 
had  occurred  between  1913-1917  were  tabulated.  As  this  fund  has  a 
waiting  period  of  only  three  days,  a  larger  number  of  short  illnesses 
are  included  than  in  the  studies  of  the  other  funds.  Seventy-four  per 
cent,  of  the  cases  lasted  less  than  two  weeks,  and  15  per  cent.  trojH 
two  to  four  weeks,  leaving  only  11  per  cent,  in  the  group  which  lasted 
longer  than  one  month-^  When  we  deduct  the  27,234  cases  of  less 
than  eight  days  duration,  we  find  that  the  proportion  of  the  remainder 
which  lasted  less  than  two  weeks  is  reduced  to  55.7  per  cent.,  and  that 
18.11  per  cent,  lasted  longer  than  one  month.  As  this  Fund  pays  sick 
benefits  during  the  entire  period  of  illness,  and  as  only  completed 
cases  were  included  in  the  study,  there  were  undoubtedly  a  very  large 
number  of  chronic  and  serious  cases  of  more  than  one  month's  dura- 
tion which  were  still  receiving  benefits  and  for  that  reason  were  not 
recorded. 

It  is  clear  that  of  course  the  shorter  the  "waiting  period,"  the  larger 
the  percentage  of  short  illnesses.  Statistics  from  one  fund  which 
pays  benefits  from  the  first  day  of  illness,  were  studied.*    The  results 

(i)See  Table  XI  at  end  of  Section. 

(*)See  Table  XII  at  end  of  this  section. 

(S)See  Table  XIII  at  end  of  this  section. 

(*)Data  for  a  ftve-year  period,  1912  to  1916  inclusive,  for  approximately  47,000  persons  in  some 
42  different  occupational  groups  was  made  available  to  the  Commission  inj  advance  of  publication 
through  the  kindness  of  Dr.  Royal  Meeker,  of  the  Bureau  of  Labor  Statistics. 


57 

of  five  years'  experience  showed  that  19.1  per  cent,  of  the  illnesses 
in  this  group  were  of  less  than  one  week's  duration.  Forty-six  and 
eight  tenths  per  cent,  lasted  less  than  two  weeks,  and  a  total  of  71.5 
per  cent,  lasted  less  than  a  month.  Of  the  28.5  per  cent,  lasting  ov<vr 
one  month,  more  than  two-thirds  were  between  one  and  four  months?, 
iind  2.2  per  cent.,  or  954  cases,  were  over  six  months  in  duration. 

However  we  may  interpret  these  varying  figures,  we  are  strucl; 
with  the  fact  that  in  all  the  different  groups  studied  at  least  one- 
third  of  the  illnesses  are  of  relatively  long  duration,  and  when  we 
/Idealize  that  a  large  proportion  of  those  who  are  ill  are  the  house- 
keepers or  wage-earners  whose  sickness  means  not  only  expenditures 
for  medical  and  hospital  care,  but  also  suspension  of  the  family  in- 
come, we  begin  to  see  the  enormity  of  the  burden  which  sickness  is  im- 
posing. 

EXTENT    OF    SICKNESS    IN    PENNSYLVANIA    AS    SHOWN    BY    DRAFT 
REJECTIONS  FOR  PHYSICAL  CAUSES.i 

Another  index  of  health  conditions  among  a  considerable  group  of 
Pennsylvania  employees  is  the  proportion  of  rejections  for  physical 
cases  in  the  draft  of  April,  1917.  The  men  of  draft  age  may  be  as- 
sumed to  be  at  the  height  of  their  physical  powers.  Yet  in  Pennsyl- 
vania the  proportion  of  those  examined  who  were  rejected  for 
physical  causes  was  46.67  per  cent.^  This  was  the  highest  proportion 
found  in  any  state  in  the  union,  the  average  for  the  whole  United 
States  being  but  29.11  per  cent.  It  is  unfortunate  that  the  rejections 
by  the  various  local  boards  are  not  given  on  the  same  basis  so  that 
variations  in  different  localities  can  be  discussed  at  this  time.  In- 
dividual boards  and  physicians  may,  of  course,  vary  in  the  strictness 
of  their  examinations,  but  it  would  seem  that  over  a  whole  state  these 
differences  would  tend  to  balance  each  other. 

The  years  from  twenty-one  to  thirty-one  are  those  in  which  men 
should  be  vigorous  and  fit,  in  prime  physical  condition.  The  draft 
army  represents  a  large  proportion  of  our  wage-earning  population, 
and  the  figures  in  the  Provost  Marshal  General's  report  are  startling. 
When  almost  half  the  men  examined  are  not  in  condition  for  military 
service,  something  is  radically  wrong. 

The  conclusion  seems  justified  that  Pennsylvania  men  between 
twenty-one  and  thirty-one  years  of  age  are  in  poorer  physical  condi- 
tion than  in  any  other  state.^  This  fact  is  not  surprising,  however, 
when  we  consider  that  almost  three-fourths  of  our  school  children 
who  are  examined  are  found  to  be  physically  defective.  The  nature 
of  the  defects  found  among  both  the  school  children  and  m,en  of  draft 
age  are  discussed  in  section  V. 


offlS^y^fthl'^rVolf  ^lafshS^GeSSal.  ''  '^^«^^""^««   <^^^-^   -J««««-   *«  -<^  being  made   In   the 
lal^^^P^m  ^/  *x^  ProvoBt  Marshal  General  to  the  Secretary  of  War;  Norember    1917. 
C^See  Table  I   at  end   of  this   section. 


5S 

EXTENT  OF  ILLNESS  BY  SEX  AND  AGE. 

The  results  of  the  Philadelphia,  the  Western  Pennsylvania  and 
the  Pittsburgh  Sickness  Surveys  have  been  tabulated  to  show  the 
extent  of  sickness  by  sex  and  age  groups.^  The  general  experience 
under  health  insurance  laws  shows  a  higher  sickness  rate  for  females 
than  for  males.  In  contrast  to  this,  both  the  Western  Pennsylvania 
Survey  and  the  figures  for  Pittsburgh  alone  show  a  lower  rate  for 
females,  where  all  ages  are  considered,  but  in  the  age  groups  fifteen 
to  thirty-four  the  sickness  rates  for  females  are  higher  than  the  cor- 
responding rates  for  males,  both  for  all  illnesses,  and  for  disabling 
illness.  In  the  Philadelphia  Survey  however,  the  rate  for  illnesses  at 
all  ages  was  slightly  higher  for  females  than  for  males,  4.3  per  cent, 
instead  of  4.2  per  cent.,  but  for  disabling  sickness  it  was  1.4  per 
cent,  for  females  and  1.7  per  cent,  for  males.  The  difference  in  favor 
of  the  female  sex  does  not  show  itself  clearly  until  the  age  period 
thirty-five  to  forty-four  years  is  reached.  In  the  earlier  years,  cover- 
ing childhood  and  the  principal  periods  of  childbearing  and  wage- 
earning  for  the  sex,  the  sickness  rate  is  slightly  higher  in  most  cases, 
bearing  out  the  experience  under  Health  Insurance.^ 

A  possible  explanation  of  these  differences  in  the  sickness  rates  of 
males  and  females  suggests  the  responsibility  of  industry  for  a  cer- 
tain part  of  existing  illness.  The  great  majority  of  women  between 
thirty-five  and  sixty-five  years  of  age  are  housewives,  whereas  most 
men  are  gainfully  employed  during  this  age  period.  Not  only  the 
direct,  but  the  cumulative  effect  of  industrial  conditions  may  begin 
to  be  felt  in  middle  life,  and  thus  appreciably  raise  the  sickness  rate 
of  older  men.  The  higher  rate  for  women  under  Health  Insurance 
applies  only  to  working  women,  and  most  women  workers  are  found 
in  the  age-groups  fifteen  to  thirty-five  years. 

Such  an  explanation  is  borne  out  by  the  statement  of  Dr.  B.  S. 
Warren  and  Mr.  Edgar  Sydenstricker  of  the  United  States  Public 
Health  Service,  that: 

"In  view  of  the  generally  accepted  fact  that  in  the  population  as  a 
whole  the  female  mortality  rate  is  less  than  the  male,  it  would  seem 
reasonable  to  assume  that,  excluding  confinements,  the  female  mor- 
bidity rate  is  not  greater  than  the  male.  Among  women  employed 
as  wage-workers,  however,  these  conditions  are  apparently  reversed.''^ 

Variations  in  the  sickness  rate  according  to  age  are  simpler  than 
the  sex  differences.  There  is  a  steady  rise  in  each  case  from  the 
youngest  to  the  oldest  groups,  with  the  exception  of  disabling  sickness 
for  females  in  the  Philadelphia  Survey.     In  that  case,  the  rate  for 


(») White  persons  only   in  Western   Pennsylvania. 
(2) See  Tables  VI,   VII  and  VIII  at  the  end  of  this  section. 

(*)B.  S.  Warren  and  Edgar  Sydenstricker;  Health  Insurance:     Its  Relation  to  .the  Public  Health, 
Bulletin  76,  page  28. 


59 

the  years  thirty-five  to  forty-four  is  slightly  lower  than  for  the  twenty 
years  preceding.  This  again  points  to  the  possible  influence  of  wage- 
earning  and  child-bearing  in  the  Philadelphia  group. 

EXTENT  OF  SICKNESS  BY  COLOR,  RACE  AND  LOCATION. 

The  negro  population  has  a  higher  sickness  rate  than  the  white, 
according  to  available  evidence.  Since  negroes  from  the  south  are 
at  present  migrating  to  Pennsylvania  in  large  numbers,  this  means 
the  possibility  of  a  great  increase  in  the  sickness  problem  of  the 
j^tate,  particularly  during  the  period  of  acclimation  when  pre-dis- 
position  to  disease  is  markedly  shown.  The  average  daily  sickness 
rate  among  white  policy-holders  in  the  Western  Pennsylvania  Survey 
was  1.75  per  cent ;  among  colored,  2.08. 

In  each  city  for  which  these  comparative  figures  have  been  tabu- 
lated, negroes  have  the  larger  amount  of  sickness.  In  Pittsburgh  the 
rates  were  1.62  per  cent,  for  whites  and  1.72  for  negroes ;  in  Brad- 
dock,  1.56  and  2.34;  in  McKeesport,  1.95  and  2.41;  in  Uniontown,  2.22 
and  2.79  respectively.^ 

Three  of  the  seven  districts  covered  by  the  Philadelphia  Survey 
were  inhabited  mainly  by  negroes,  and,  while  the  average  sickness 
rate  found  in  the  survey  was  4.28  per  cent,,  the  rates  in  these  districts 
were  4.45,  9.30  and  3.87  per  cent.,  respectively.  The  abnormal  rate 
of  9.30  was  in  a  district  of  negroes  fresh  from  the  south,  receiving  low 
wages  and  living  under  crowded,  insanitary  conditions.  Dr.  Miller, 
who  had  the  survey  in  charge,  felt  that  unless  drastic  measures  to 
improve  health  conditions  were  taken  in  this  neighborhood,  there 
was  danger  of  an  epidemic  which  might  menace  the  city. 

If  we  consider  mortality  statistics  as  an  indication  of  the  extent 
of.  sickness,  the  same  high  rate  among  negroes  appears.  In  1916  the 
death  rate  in  Pennsylvania  from  all  causes  was  14.3  per  1,000  white 
persons  as  against  23.6  for  the  colored  population. 

The  rate  among  negroes  in  the  cities  was  about  15  per  cent  higher 
than  among  those  in  the  rural  districts.  Analyzed  by  diseases,  the 
greatest  differences  appear  in  organic  heart  diseases,  pneumonia  and 
tuberculosis  in  all  its  forms,  where  the  rates  for  the  colored  are  more 
than  double  those  for  the  white  population.  Tuberculosis  of  the 
lungs,  for  instance,  had  a  rate  in  1916  of  105.0  per  100,000  for  the 
white  population,  but  a  rate  of  389.3  for  the  colored.  Other  forms  of 
tuberculosis  showed  rates  of  7.7  vs.  16.3  and  9.4  vs.  25.8,  more  than 
twice  the  rate  for  the  white  population  in  each  case.  Communicable 
diseases,  diabetes,  cancer  and  suicide  are  apparently  slightly  less 
frequent  among  the  colored  than  among  the  white. 

The  Metropolitan  Life  Insurance  Company  made  for  the  Commis- 
sion a  special  compilation  of  claim-rates  in  Pennsylvania  among 
Industrial  Policy  Holders,  classifying  the  insured  by  color,  over  a 

(»)See  Table  V  at  the  end  of  this  section. 


CO 

period  of  three  years — 1915,  191G,  and  1917.^  Kates  are  given  for 
twenty-six  localities  in  the  state,  in  addition  to  fourteen  districts  in 
Philadelphia  and  four  in  Pittsburgh.  In  practically  every  instance, 
the  rates  are  from  50  to  100  per  cent,  higher  for  the  colored  than  for 
the  white  policy-holders.  For  the  entire  state  the  claimrates  were 
12.4  for  the  white,  in  1917,  and  15.7  for  the  colored.  In  Allentown, 
Erie,  Johnstown,  McKeesport  and  York,  the  rate  for  the  colored  was 
practically  double  that  for  the  white,  although  in  Bristol,  Pottstown, 
Pottsville  and  Scranton,.  it  was  appreciably  lower.  These  claimrates^ 
of  course,  must  be  viewed  in  the  light  of  varying  sex  and  age  charac- 
teristics of  the  several  groups,  and  of  the  degree  to  which  the  com- 
pany has  developed  its  Nursing  Service  in  the  district. 

Examining  the  claimrates  by  cause  of  death,  the  same  differences 
appear  as  are  evident  from  the  general  mortality  statistics  of  the 
state.  Deaths  from  typhoid  fever,  tuberculosis,  and  pneumonia,  show 
decidedly  higher  rates  for  the  colored,  while  communicable  diseases, 
cancer,  cerebral  hemorrhage  and  external  causes  are  somewhat  lower. 

In  1910  there  were  193,919  negroes  in  Pennsylvania,  an  increase  of 
23.6  per  cent,  over  the  number  in  1900.  The  great  majority  of  the 
108,186  who  were  gainfully  occupied,  were  unskilled  laborers,  ser- 
vants, teamsters,  and  laundresses — belonging  to  a  group  where 
standards  of  wages,  housing^  and  occupation  subject  them  to  special 
hazards.  Philadelphia  in  .1910  ranked  fifth  among  the  cities  of  over 
100,000  population  in  A^hich  lived  more  than  1,000  negroes,  and  the 
increase  had  been  34.9  per  cent,  over  the  number  in  1900.  In  Pitts- 
burgh the  increase  had  been  25.9  per  cent.  It  is  probable  that  since 
1910  the  increase  in  the  negro  population  has  been  much  greater.  As 
Dr.  Miller  says,  unless  drastic  measures  are  taken  to  improve  health 
conditions,  the  negro  population  may  become  a  serious  danger. 

The  newer  immigrants  from  overseas  appear  in  the  Philadelphia 
survey  to  have  a  lower  sickness  rate  than  the  whole  area  surveyed. 
The  district  inhabited  by  Jews,  Poles,  and  Austrians  had  a  sickness 
rate  of  3.88  per  cent. ;  the  Italian  district,  one  of  3.23  per  cent.,^  as 
•igainst  the  average  rate  of  4.28  found  in  the  survey. 

Considerable  variation  in  different  localities  is  brought  out  by  the 
sickness  rates  for  various  towns  in  the  Western  Pennsylvania  Sur- 
vey. The  highest  rate  for  Avhite  persons  is  2.22  ])er  cent.  iJi 
Uniontown,  the  lowest,  1.56  in  Braddock,  a  difference  of  42  per  cent. 
What  the  main  factors  in  producing  such  a  difference  may  be, 
whether  race,  age  distribution,  epidemic,  occupation,  or  general 
sanitary  conditions,  we  have  at  present  no  means  of  knowing 

As  a  rule,  however,  it  would  seem  that  in  the  industrial  communi- 
ties of  the  state  and  the  parts  of  large  cities  inhabited  chiefly  by 
wage-earners,  the  sickness  rates  are  much  higher  than  in  residential 


(i)See  Table  XVIT  at  end  of  this  section. 
(2) See  Table  IX  at  the  end  of  this  section. 


61 

sections.  In  the  Western  Pennsylvania  Survey  the  six  highest  sick- 
ness rates  in  the  fifteen  districts  enumerated  were  those  for  Union- 
town,  2.22;  Altoona,  2.16;  Scranton,  2.10;  Shamokin,  2.08;  McKees- 
port,  1.95;  and  Shenandoah,  1.88.  Death  rates  indicate  the  same 
tendency.  For  instance,  the  United  States  Public  Health  Service 
j^hows  that  the  death-rate  throughout  the  United  States  registration 
area  in  1913  was  14.1  per  1,000  of  population,  but  in  Johnstown  it 
was  16.9 ;  in  McKee's  Kocks,  16.9 ;  in  Shenandoah,  18.9 ;  and  in  Brad- 
dock,  23.2.^  It  is  further  stated  that  ^'As  it  is  generally  recognized 
that  mortality  returns  in  localities  of  this  type  are  more  or  less 
incomplete,  it  is  safe  to  say  that  the  rates  cited  are  lower  than  more 
thorough  and  complete  vital  statistics  would  show." 

This  fact  is  brought  out  particularly  by  studies  of  infant  death 
rates,  and  of  the  death  rates  of  the  professional  vs.  the  wage  earning 
groups  in  various  communities. 

An  interesting  comparison  is  made  by  Dr.  Hayhurst  in  his  study 
of  Occupational  Diseases  in  Ohio,  between  the  death  rates  among 
members  of  the  professional  class,  and  those  in  a  wage  earning  group. 
Six  preventable  causes  of  death  were  taken  and  a  higher  death  rate 
was  found  from  each  of  the  six,  among  the  wage  earning  group.  The 
death  rates  from  "tuberculosis'^  and  "accidents  and  injuries"  for  the 
wage  earning  group  were  more  than  double  those  for  the  professional 
group. 


Mortality  Rate 

per  100 

Deaths. 

1 

eT 

o 

A 

Q. 

3 

2 

•e   . 

iu( 

s& 

tar 
a 

c 

g^ 

t-t 

03 

ii^ 

o 

II 

^ 

Ph 

^ 

IHiberculosis,         — _      _    _  -      

8.22 
5.20 
6.89 
2.13 
1.88 
.43 

17.53 

Accident  and  injuries 

11  85 

Pneumonia                                                   -    

8  48 

Suicide                                     _  _         -_    

2.76 

Typhoid                           : - 

2.35 

.78 

Total,   

24.75 

43.75 

A  comparison  of  rural  and  urban  death  rates  indicates  that  while 
the  urban  death  rate  is  higher  than  the  rural,  within  the  last  ten 
years  greater  decreases  in  this  rate  have  been  effected  in  cities  than 


<')U.   S.  Public  Health  Bulletin,  No.   76,  p.   27. 

(*)I3.    R.    Hayhurst,    Industrial    Health    Hazards    and    Occupational    Diseases    in    CMiio, 
Table  cooipiled  from  United  States  Bureau  of  Vital  Statistics  Report. 


page    16. 


G2 

in  country  districts.  In  Pennsylvania  both  the  rural  and  the  urban 
rates  are  higher  than  the  corresponding  rates  for  the  registration 
area  as  a  whole.  From  1906  to  1916  the  decrease  of  the  urban  death 
rate  in  the  state  was  three  times  as  great  as  the  decrease  in  the 
rural  districts. 

EXTENT  OF  SICKNESS  AS  SHOWN  BY  THE  GENERAL  DEATH 
RATES  IN  PENNSYLVANIA, 

The  extent  of  sickness  in  the  State  Cdn  be  t*ougiily  efetitn^ted  by  A 
study  of  death-rates,  sihctS  mortality  statistics  are  considered  to  soin© 
isxtent  an  inde-X  of  mt>i*bidity  rates.  Pennsylvania  has  been  part  of  ■ 
the  United  States  registration  area  for  death-rates  since  1906,  and  it 
is  therefore  possible  to  study  the  death  fates  in  the  state  from  that 
year.  The  last  published  fates  are  those  for  1916,  obtained  from  the 
0en8u8  Volume  On  Mortality  Statistics.  Unfortunately  the  last 
ptibiiished  report  of  the  state  board  of  health  is  for  1914. 

In  spite  of  a  general  decrease  in  the  death-rate,  certain  most 
alarming  features  afe  evident.  In  [Pennsylvania  the  death-rate  as  a 
whole  fell  from  16.0  pef  1,000  of  the  population  in  1906  to  14.6  in 
1016,  or  8.7  pef  Cent.^  But  the  rate  in  Pennsylvania  from  diseases 
of  the  circulatory  system  rose  from  149.3  to  189.8  per  100,000,  or  27.1 
X>Qt  e^nt.,  and  for  genitourinary  diseases  (nonvenereal)  from  101.1 
to  120.5  per  100,000  or  19.1  per  cent. 

In  1916,  Pennsylvania  showed  a  higher  death  rate  in  nine  of  the 
fourteen  groups  in  the  International  Classification  of  diseases  than 
the  rate  for  the  registration  area.  The  general  death  rate  per  1,000 
population  in  1916  was  13.9  for  the  registration  area,  and  14.6  for 
l*ennsylvania»  The  greatest  difference  was  between  the  rates  for 
deaths  from  diseases  of  the  respiratory  system,  where  Pennsylvania 
had  a  rate  of  202.3  per  100,000  and  the  registration  area  165.4. 
Between  1915  and  1916  in  Pennsylvania  marked  increases  in  the 
<3ftath  rates  are  noted  in  nine  of  the  fourteen  international  disease 
classifications. 

Marked  increases  were  noted  in  Chester,  the  general  death  rate 
there  being  21.1  per  thousand  in  1916,  whereas  it  had  been  16.1  in 
1915 ;  in  Philadelphia  the  rate  increased  from  15.6  in  1915  to  16.2  in 
1916  and  showed  a  furtlier  increase  in  1917  to  17.1,  higher  than  either 
the  New  York  or  the  Chicago  rate.  In  Pittsburgh  the  rate  was 
higher  and  the  increase  more  rapid.  In  1915  it  was  15.2;  in  1916  it 
rose  to  17.4  and  in  1917  to  18.1. 

The  most  significant  decreases  in  the  death  rate  in  the  last  ten 
years  have  been  made  in  those  diseases  which  can  be  controlled  in 
large  measures  by  community  action.  Typhoid  fever  dropped  from 
54.8  per  100,000  in  the  state  in  1906  to  13.6  per  100,000  in  1916. 
Most  of  this  decrease  has  been  in  the  urban  rate.     In  Philadelphia 

(1)  Table  XV  at  the  end  of  this  section  glyes  the  dipath  jates  in  Pennsylvania  for  the  various 
classes  of  diseases  between  1906  and  3  916,  


63 

the  rate  has  fallen  from  74.3  to  7.0,  and  in  one  year,  1914,  it  was 
reduced  from  15.7  to  7.6.  In  Pittsburgh  the  rate  from  typhoid  has 
lluctuated  from  141.1  in  1906  to  9.0  in  1916. 

In  a  study  published  in  1916,  called  "The  Sanitary  Index,"^  Dr. 
Batt  expresses  the  opinion  that  the  decline  in  the  death  rate  during 
the  last  ten  years  is  not  satisfactory  outside  "those  diseases  that  are 
the  objects  of  sanitary  attack."  He  enumerates  among  the  latter  the 
"acute  communicable  diseases  of  epidemic  type,"  infant  mortality, 
and  tuberculosis.  These  diseases  form  "the  adopted  field  of  public 
health  activities,"  and  the  death-rate,  from  them  is  termed  "the 
Banitary  Index."  The  death-rate  from  the  other  diseases,  which 
make  up  about  three-fifths  of  the  total  mortality,  is  called  the  "resi- 
dual death-rate/^  Br.  Batt  points  out  that  while  the  "sanitary 
index"  decreased  from  6.5  to  4.5  per  1,000,  or  30.8  per  cent.,  between 
1906  and  1915,  the  "residual  death-rate"  fell  only  from  9.5  to  9.3  or 
2.1  per  cent.  It  increased  in  second  and  third-class  cities  and  in  bor- 
oughs of  less  than  10,000  population.  Dr.  Batt  concludes : 

"It  is  therefore  apparent  that  almost  the  entire  reduction  that  has 
taken  place  in  the  general  death-rate  has  been  due  to  the  decline  in 
the  deaths  from  those  diseases  that  are  the  objects  of  sanitary  attack. 

"By  the  segregation  of  the  causes  of  death  into  two  groups  we  are 
also  bringing  into  due  prominence  through  the  residual  death  rate 
the  necessity  for  safeguarding  industrial  workers  and  for  personal 
hygiene  on  the  part  of  individuals.  Old  age  should  be  the  pre- 
eminent, cause  to  be  attained  in  this  group."^ 

In  other  words,  the  death-rate  gives  direct  evidence  of  the  greatest 
need  for  discovering  ways  and  means  to  protect  the  lives  of  indus- 
trial workers  whose  health  now  is  the  least  carefully  preserved  and 
is  subject  to  the  greatest  hazards. 

In  a  study  of  death  rates  in  the  state  from  the  four  special  causes 
which  most  emphasize  the  community's  responsibility  for  health  con- 
ditions, typhoid  fever,  tuberculosis  of  the  lungs,  diarrhea  and  enteri- 
tis, and  accidents,  we  find  that  in  Pennsylvania  the  rates  are  higher 
for  three  out  of  four  of  these  causes  than  are  the  corresponding  rates 
for  the  registration  area.''' 

The  rates  for  all  four  causes  of  death  decreased  materially  during 
the  ten  year  period,  but  in  every  case  they  increased  alarmingly 
between  1915  and  1916;  diarrhea  and  enteritis  from  90.7  to  101.7, 
accidents  from  92.6  to  107.8,  typhoid  fever  from  12.3  to  13.6,  tubercu- 
losis of  the  lungs  from  110.6  to  112.3  per  100,000.  Altogether  these 
four  causes  accounted  for  approximately  one-fifth  of  the  total  number 
of  deaths  in  the  state  in  1916,  and  the  death  rate  from  diarrhea  and 
enteritis  is  the  most  important  factor  in  determining  the  infant  death 
rate.  In  1916  in  the  registration  area  this  was  the  cause  of  almost 
25  per  cent,  of  the  deaths  under  one  year  of  age. 

(i)PeTmsylTania  Hoalth  Bulletin,   February,   1916. 

(2) While  Dr.  Batt  includes  tuberculosis  in  the  "sanitary  index,"  Dr.  Miller  of  the  Philadelphia 
Bureau  of  Health  states  that  "The  tuberculosis  death-rate  remains  practically  constant  with  little 
fluctuation   from   year  to  year." 

(S)See  Table  XV  at  the  end  of  this  section. 

5 


64 

'Pbe  possible  power  of  control  over  these  four  causes  of  death  is 
well  illustrated  by  the  reductions  which  individual  districts  have 
succeeded  iu  making.  Typhoid  fever  has  been  spoken  of.  Just  as 
marked  is  tlie  reduction  in  the  rate  from  accidents  which  Pittsburgh 
and  Scranton  made  in  ihe  ten  year  period  1906-1916,  or  the  decrease 
in  deaths  from  diarrhea'  and  eiiteritis  affected  in  Philadelphia,  during 
the  same  period.^  The  rate  from  diseases  of  the  puerperal  state  in 
Pennsylvania  increased  from  16.^'  pet  100,000  in  1906  to  18.0  in  1916. 
The  figures  of  the  Philadelphia  Burea'ti  of  Vital  Statistics  show  that 
in  1917  there  were  in  the  city«259  deaths  of  women  from  disea^s  of 
the  puerperal  state.  Since  the  total  number  of  births  was  43,06#„ 
this  makes  a  rate  of  over  six  per  thousand — or  over  600  per  100,000) 
births. 

The  crying  necessity  for  improved  maternity  care  is  clearly  illus- 
trated   by    these    figures.     The    United    States    Children's^   Bureau', 
estimates   that   over  half  the   deaths   from   causes   connectecf  with> 
childbirth  are  preventable.     The  time  of  confinement  is  the  fi»st 
critical  period  in  the  lives  of  both  mothers  and  babies,  and  ev€ftyr 
means  should  be  used  to  provide  protection  for  these  lives  at  this 
crucM  titae.     Kot  only  may  the  future  health  of  the  particular  child 
depend  upon  this  care,  but  the  lives  and  health  of  many  more  poten- 
tial babies  whose  streng^th  so  often  is  permanently  impaired  through 
inadequate  care  of  the  mother  at  childbirth. 

INFANT  DEATH-RATE. 
Since  infant  mortality  is  truly,  as  it  has  been  called  by  the  great 
English  authority,  Sir  Arthur  Newsholme,  "the  most  sensitive  index 
we  possess  of  social  welfare  and  of  sanitary  adminij^ration,"  theu, 
indeed,  health  conditions  in  Pennsylvania  demand  improvement,  and 
never  before  so  insistently.  Tlie  Avar  has  taught  us  conser\v;i^i^ii  on 
every  hand,  but  particularly  the  conservation  of  the  lives  of  t^ose 
who  must  carry  on  the  ideals  for  which  our  soldiers  went  to  deathi — 
the  lives  of  little  children,  upon  whom  rest  the  future  of  the  nation.. 
And  in  so  far  as  Pennsylvania  has  been  extraordinarily  waste1!ul  im 
the  past,  she  must  now  make  every  effort  to  make  good  the  loss,  and? 
allow  no  life  to  be  needlessly  sacrificed.  What  once  might  have  beem 
considered  a  humanitarian  task  now  becomes  a  patriotic  necessity- 
President  Wilson,  in  approving  the  plan  for  "Children's  Year" 
recently  inaugurated  by  the  Children's  Bureau  and  the  Woman's 
Committee  of  the  Council  of  National  Defense,  said : 

"Next  to  the  duty  of  doing  everything  possible  for  the  soldiers  at 
the  front,  there  could  be,  it  seems  to  me,  no  more  patriotic  duty  than 
that  of  protecting  the  children,  who  constitute  one-third  of  our  popu- 
lation. 

"The  success  of  the  efforts  made  in  England  in  behalf  of  the  chil- 
dren is  evidenced  by  the  fact  that  the  infant  death  rate  in  England 
for  the  second  year  of  the  war  was  the  lowest  in  her  history.    Atten- 

(i)See  Table  XVI  at  the  end  of  this  section. 


65 

tion  is  now  being  given  to  education  and  labor  conditions  by  the 
legislatures  of  both  France  and  England,  showing  that  the  conviction 
among  the  allies  is  that  the  protection  of  childhood  is  essential  to 
winning  the  war." 

The  infant  death-rate  in  Pennsylvania  in  1916  was  110  per  1,000 
births ;  in  1916,  114  per  1,000.  The  county  having  the  lowest  rate  in 
1915  was  Cameron,  with  53  per  1,000  the  highest,  Fayette,  with  160 
per  1,000.^  In  1917,  the  death-rate  for  children  less  a  year  old 
was  higher  in  Philadelphia  than  in  any  other  city  of  similar  size 
(over  1,000,000)  in  the  United  States.  The  rate  in  Philadelphia  was 
101.0  per  1,000  living  births  in  1916.  This  increased  to  110  in  1917. 
The  rate  in  Brooklyn  in  1917  was  84.9  and  in  New  York  88.8.  The 
rate  for  the  registration  area  as  a  whole  was  101.  The  Pittsburgh 
rate  in  1917  was  116.2.  This  was  the  second  highest  rate  for  any  city 
in  the  country  of  150,000  population. 

Every  city  in  the  United  States  with  a  population  of  over  500,000, 
had  a  material  decrease  in  the  infant  mortality  rate  between  1916 
and  1917  with  the  exception  of  Philadelphia,  Pittsburgh  and  Balti- 
more. The  increases  in  both  Philadelphia  and  Pittsburgh  were  much 
greater  than  in  Baltimore,  although  the  Baltimore  rate  was  higher. 
In  1916  and  1917  the  infant  mortality  rate  in  Pittsburgh  formed  18 
per  cent,  of  the  total  mortality.  Among  cities  having  less  than 
50,000  population,  Norristown  had  the  highest  rate  in  the  country  in 
1917—167.7  per  1,000.  Five  cities  of  similar  size  had.  infant  death 
rates  in  1917  of  less  than  50  per  1.000. 

A  comparison  of  these  shamefully  increasing  Pennsylvania  rates 
with  those  shown  by  countries  where  intelligent  and  patriotic  meas- 
ures are  being  taken  to  preserve  the  lives  of  children  by  adequate  pre- 
ventive measures  is  illuminating.  The  infant  mortality  rate  in  Eng- 
land in  1916  was  only  91  per  1,000,  the  lowest  in  her  whole  history, 
while  New  Zealand  succeeded  in  reducing  her  infant  deaths  from  80 
per  1,000  in  1907  to  50  in  1915. 

The  differential  death-rate  between  industrial  and  residential 
localities  is  particularly  marked  in  connection  with  infant  mortality. 
For  instance,  in  Pittsburgh,  in  the  year  ending  April  1,  1916,  the 
infant  death-rate  in  the  crowded  twenty-second  ward  was  135.9.  In 
the  fifteenth,  along  the  river  in  a  mill  district,  it  was  121.9.  In  the 
seventh  and  the  fourteenth  wards,  which  are  high-grade  residential 
sections,  it  was  60.4  and  89.5  respectively.^ 

The  United  States  Public  Health  Service  found  as  marked  an  excess 
in  the  proportion  of  infant  deaths  in  the  iron  and  steel  towns  of  the 
state  as  in  the  general  death-rate.  In  these  towns,  moreover,  wage 
work  by  mothers  of  young  children,  to  which  high  infant  mortality 

t^) Figures    supplied    by    Pennsylvania    Department    of    Health    to    Chief    of    Division    of    Child 
Hygiene,    1918. 

(*) Dispensary  Aid   Swief;y,   Tuberculosis  League  of -Pittsburgh,    1st  Survey  Report,   pages   50-51. 


66 

iiy  often  attributed,  was  very  infrequent ;  yet,  while  deaths  of  children 
under  five  formed  27  per  cent,  of  all  deaths  in  the  United  States 
registration  area  during  the  five-year  period — 1909-1913,  10  per  cent, 
and  17  per  cent,  in  the  residential  towns  of  Brookline,  Massachusetts 
and  East  Orange,  New  Jersey,  they  were  67  per  cent,  of  all  deaths  in 
Monessen,  57  per  cent,  in  Homestead,  55  per  cent,  in  South  Bethle- 
hem, 51  per  cent,  in  Braddock,  47  per  cent,  in  Carnegie,  45  per  cent, 
in  Steelton,  and  40  per  cent,  in  Johnstown.^ 

The  first  of  the  well-known  studies  of  infant  mortality  of  the 
Federal  Children's  Bureau  was  made  in  Johnstown,  and  furnishes 
additional  information  on  the  dangerous  state  of  Pennsylvania's 
infant  death-rate.  The  investigation  covered  all  of  the  Johnstown 
children  born  in  1911,  who  could  be  traced,  and  all  death-rates  are 
based  on  the  number  of  this  group  who  died  within  one  year  of  birth. 

There  is  a  marked  difference  in  that  city  also  in  the  infant  death- 
rates  in  residential  and  industrial  sections.  In  the  downtown  section 
where  the  homes  of  many  of  the  well-to-do  are  found,  the  rate  of 
infant  deaths  was  only  50  per  1,000.  In  Kernville,  which  also  con- 
tained a  large  proportion  of  prosperous  families,  it  was  57.7.  The 
rate  in  Woodvale,  among  unskilled  mill  workers,  was  271  per  1,000, 
and  in  Prospect,  near  one  of  the  large  steel  plants,  it  was  200  per 
1.000.  The  average  rate  for  the  city  as  a  whole  was  134  per  1,000. 
Other  tabulations  show  the  difference  in  the  rate  according  to  the 
kind  of  infant  care.  For  mothers  who  were  attended  by  physicians 
at  confinement,  the  rate  was  100.5,  93.2  for  Americans  and  139.7  for 
the  foreign  bom,  but  the  rate  was  179.7  in  all  cases  in  which  a  mid- 
wife attended  the  birth,  there  being  no  appreciable  difference  in  the 
rate  between  native  and  foreign-born.  Most  striking  of  air  is  the 
difference  in  the  rate  according  to  the  income  of  the  father.  In  cases 
where  fathers  had  incomes  of  |521.00  a  year  or  less,  the  rate  of  infant 
mortality  was  197.3 ;  it  steadily  declined  in  the  higher  income  groups, 
reaching  102.2  in  cases  in  which  the  father's  annual  income  was 
^t^l  ,200.00  or  more.2 

The  health  problem  then  seems  to  be  largely  dependent  upon  the 
standards  of  living  and  the  economic  status  of  the  family,  and  the 
responsibility  for  making  these  what  they  should  be  rests  not  only 
upon  the  individual  effort,  but  in  a  large  measure  upon  the  com- 
munity. 

The  conclusion  reached  by  the  Children's  Bureau  is  that : 

"The  Johnstown  report  shows  a  coincidence  of  MiidtrpHid  fnthers 
overworked  and  ignorant  mothers,  and  those  hazards  to  the  life  of 
the  offspring  which  individual  parents  cannot  avoid  or  control 
because  they  must  be  remedied  by  community  action." 

A  similar  need  exists  in  many  other  places  besides  Johnstown. 
The  problem  will  no  doubt  be  rendered  more  acute  by  the  inevitable 

(') United  Pta-tps  Public  Health  Bulletin  No.   76,  page   27. 
(2) See  Table  XIX  at  the  end  of  this  section. 


67 

influx  of  married  women  into  industry  as  the  war  continues.  Even 
in  the  last  year  or  two  before  the  war,  the  rising  cost  of  living  caused 
many  mothers  to  take  up  work  outside  their  homes. 

It  is  now  especially  imperative  that  the  state  increase  its  efforts 
to  provide  more  adequate  maternity  care  and  to  conserve  the  lives  of 
mothers  and  babies. 

KINDS  OF  SICKNESS. 

Evidence  as  to  the  relative  prevalence  of  various  kinds  of  diseases 
may  be  drawn  from  facts  in  the  various  surveys  and  records  and 
from  the  only  official  sickness  statistics  in  the  state,  those  of  "report- 
able" diseases.  Owing  to  differences  in  the  way  in  which  they  are 
collected,  the  significance  of  these  figures  must  not  be  exaggerated, 
but  certain  facts  stand  out  in  such  a  striking  manner  that  they  seem 
worthy  of  mention. 

The  first  point  of  special  interest  is  that  apparently  the  beginnings 
of  many  chronic  diseases  receive  no  attention.  One  of  these  is 
tuberculosis  of  the  lungs. 

In  the  Western  Pennsylvania  and  Pittsburgh  Surveys  no  attempt 
was  made  to  record  any  except  serious  and  disabling  ailments,  but  in 
the  case  of  tuberculosis  the  investigators  attempted  to  note  not  only 
all  cases  which  involved  incapacity  for  work  or  were  receiving  treat- 
ment away  from  home  in  a  tuberculosis  sanitorium,  but  all  who  wen- 
personally  aware  of  their  condition.  Thus  the  chances  are  that 
practically  all  cases  receiving  treatment  were  recorded.  Yet, 
although  this  disease  caused  7.6  per  cent,  of  the  total  deaths  in  the 
state  in  1916,  it  accounted  for  only  4.0  per  cent,  of  the  illnesses 
found  in  the  two  surveys,  apparently  confirming  the  statement  made 
in  the  report,  that  "it  is  evident  that  there  must  have  been  a  large 
number  of  undiagnosed  cases  of  tuberculosis  among  the  groups  sur- 
veyed by  our  agents." 

According  to  Dr.  Emery  R.  Hayhurst,  of  the  Ohio  State  Board  of 
Health,  "investigations  in  Ohio  show  that  there  are  seven  cases  of 
tuberculosis  to  every  death,"^  and  there  is  no  reason  to  believe  that 
conditions  in  Pennsylvania  are  radically  different.  In  1916,  tuber- 
culosis made  up  22.1  per  cent,  of  52,306  cases  of  serious  communicable 
diseases  reported  to  the  State  Department  of  Health,^  but  during 
the  same  year  it  was  responsible  for  45.7  per  cent,  of  the  deaths  from 
this  same  group  of  diseases.  Among  1,200  widows  and  their  families, 
cared  for  by  the  Mothers'  Assistance  Fund  in  1914,  tuberculosis  had 
been  responsible  for  the  death  of  the  father  in  30  per  cent,  of  the 
cases  where  the  cause  was  known. 

In  the  Philadelphia  Survey,  where  a  special  effort  was  made  to 
locate  all  tuberculosis  suspects,  the  disease  made  up  7.4  per  cent,  of 
those  reported ;  and  over  two  per  cent,  of  all  the  -persons  surveyed 


(*) Industrial  Health  Hazards  and  Occupational  Diseases  In  Ohio,   page  15.  / 

OFlgures  supplied  by  Dr.  Wllmer  R.  Batt,   State  Registrar,   Department  of  Health. 


68 

were  noted  as  suspected  cases;  in  the  Visiting  Nurse  Society  Study 
it  accounted  for  5.7  per  cent,  of  the  cases.  In  two  of  the  negro  dis- 
tricts in  the  Philadelpliia  Survey,  the  percentages  of  cases  of  tuber- 
culosis were  14.7  and  8.3  per  cent,  of  the  whole  population. 

Organic  Heart  disease  and  other  diseases  of  the  circulatory  system 
seem  also  to  escape  recognition  and  early  treatment.  The  first  of 
these  accounted  for  9.9  per  cent,  of  the  deaths  in  Pennsylvania  in 
1916,  but  made  up  only  2.8  per  cent,  of  the  illnesses  in  the  Pittsburgh 
and  Western  Pennsylvania  Surveys  and  4.2  per  cent,  of  those  in  the 
Philadelphia  Survey.  All  diseases  of  the  circulatory  system  accounted 
for  only  3.67  per  cent,  of  the  illness  cases  in  the  surveys  for  which 
they  were  recorded,  but  made  up  more  than  13  per  cent,  of  the  causes 
of  death  in  the  state  in  1916. 

The  same  evidence  seems  also  to  apply  to  cancer,  which  caused  5.2 
per  cent,  of  the  deaths  in  1916,  but  claimed  only  86  per  cent,  of  the 
diseases  in  the  surveys  where  it  was  reported  at  all. 

These  ailments  of  course  are  not  easily  detected  in  their  incipient 
stages  and  do  not  cause  complete  disability  for  work  until  well 
advanced.  For  this  reason,  some  cases  may  have  been  receiving 
treatment,  but  may  not  have  been  considered  serious  enough  to  men- 
tion to  the  investigators.  It  is  probable,  however,  that  in  most 
instances  the  diseases  had  not  been  recognized. 

In  a  group  of  four  surveys,  the  Pittsburgh  and  Western  Pennsyl- 
vania, the  Philadelphia,  the  Visiting  Nurse  Society  and  the  Sickness 
and  Dependency,  twelve  disabilities  account  for  66.4  per  cent,  of  the 
total  cases  of  illness.  These  are  in  the  order  named,  accidents  and 
injuries,  tuberculosis,  influenza,  "other  respiratory  diseases",  child- 
ren's diseases,  stomach  and  digestive  disorder,  diseases  of  the  puer- 
peral state,  rheumatism,  pneumonia,  nervous  disability,  heart  and 
circulatory  diseases,  and  typhoid  fever.  Their  relative  importance 
in  the  four  studies  varies  somewhat,  but  on  the  whole,  accidents  and 
injuries,  tuberculosis,  rheumatism  and  digestive  diseases  may  be  said 
to  be  the  most  frequent  causes  of  disability  among  the  employees 
themselves,  diseases  of  the  puerperal  state  among  the  housekeepers, 
and  "children's  diseases"  among  the  dependents.  The  comparatively 
small  proportion  disabled  because  of  industrial  accidents  in  the  Sick- 
ness and  Dependency  Study  bears  out  the  statement  of  social  workers 
that  since  the  enactment  of  the  Workmen's  Compensation  Law,  the 
number  of  families  suffering  from  such  disability  who  come  to  seek 
charitable  aid  is  much  reduced. 

Tuberculosis  accounted  for  18.2  per  cent,  of  the  illness  in  this 
study,  and  for  more  than  25  per  cent,  of  the  cases  of  disability  of  the 
wage-earner.  Fifty-eight  per  cent,  of  all  the  cases  of  tuberculosis 
were  wage-earners,  and  21  per  cent,  were  housekeepers. 


Q9 

Next  in  importance  came  diseases  of  the  puerperal  state,  which 
covered  9.2  per  cent,  of  the  total  illnesses  of  the  group,  and  31  per 
cent,  of  the  housekeepers'  disabilities.  Within  this  dependent  group 
these  two  ailments  were  more  than  three  times  as  serious  as  in  other 
surveys.  This  affords  again  confirmation  of  a  well  known  fact,  that 
tuberculosis  and  illness  connected  with  child  birth  all  too  frequently 
drive  wage-earners'  families  to  seek  charitable  relief. 

An  application  for  charitable  aid  means,  in  practically  every 
instance,  a  period  of  strain  and  struggle,  and  a  decline  in  the  stand- 
ard of  living  before  the  appeal  is  made,  conditions  which  in  maternity 
cases  are  directly  harmful  to  the  health  of  both  mother  and  child. 
Yet  the  crisis  of  child-birth  is  one  of  the  periods  when  families  are 
most  likely  to  be  forced  into  dependency,  and  the  integrity  of  the 
^family  group  to  be  threatened  at  a  time  when  it  is  most  important 
\that  it  should  be  maintained. 

The  inability  of  many  families  to  meet  this  crisis  unaided  is  again 
<&mphasized  by  a  special  study  of  418  illness  cases  cared  for  by  two 
Hvge  relief  organizations  and  studied  by  the  Bureau  for  Social 
Jlese^rch.  In  this  study,  24  per  cent,  of  the  mothers  were  ill  as  a 
result  of  child-bearing,  while  in  the  Western  Pennsylvania  Survey 
legs  than  one-tenth  of  one  per  cent,  of  the  women  of  child-bearing  age 
were  disabled  from  this  cause.  The  Bureau  for  Social  Kesearch 
found  that  the  two  main  disabilities  in  the  group  studied  were  tuber- 
culosis and  child-birth ;  28  per  cent,  of  the  mothers  and  48  per  cent, 
of  the  fathers  were  tubercular. 

From  the  investigations  made,  it  is  evident  that  the  sickness  rate 
in  the  state  and  especially  in  the  industrial  centers  and  in  the  large 
cities,  the  striking  evidence  of  lack  of  adequate  maternity  care,  and 
the  failure  to  prevent,  by  thorough  public  health  measures,  the  be- 
ginnings and  spread  of  well-known  chronic  degenerative  diseases, 
;all  point  to  the  existence  of  a  sickness  problem  that  Pennsylvania 
tcannot  afford  to  ignore. 


70 

Part  II,  Section  I,   Table  II. 
KENSINGTON  SURVEY. 
A — Nativity  of  Individuals. 


Nationality. 


United  States,   — 

Germany,    

Austria-Hungary , 

Ireland, ^ 

Russia,   

Great  Britain,  _. 
All  others, 


Number. 

Per  Cent. 

2,493 

77.9 

2J4 

6.7 

171 

6.3 

120 

3.8 

86 

2.7 

29 

0.9 

56 

1.8 

B — Number  of  Wage-Earners. 

No  information,    73  families. 

Male  heads  of  families  working,   636  persons. 

Female  heads  of  families  working,  52  persons. 

Working  mothers,  81. 

All  other  wage-earners,    590. 

Total  number  wage-earners   (exclusive  of  duplications)   1,341. 

C — Total  Weekly  Income  per  Family. 


Wage  Group. 


Number  ol 
Families. 


Per  Cent. 


Unknown 

Under  $5, 
$  5-  9.99 
$10—11.99 
$12—14.99 
$15—17.99 
$18-19.99 


$25—29.99,    

$30— and  over. 


135 
1 

14 
14 
20 
40 
54 

114 
80 

271 


2.3 
2.3 
3.3 
6.6 
8.9 
18.8 
13.2 
44.5 


♦Based  on  the  608  families  in  which  total  weekly  income  is  known. 
D — Occupations  of  Wage  Earners. 


Occupation. 


Per  Cent. 


Manufacturing  and  mechanical 

Trade,  

Domestic  and  personal, 

Laborer,    

Transportation,    

Miscellaneous,  

Public  service, 

Professional,  

Total 


100.0 


71 


E — Number  of  Oases  of  Illness  during  Year  ending  April  1,  1918. 


Number  of  Cases. 

Number 

of 
Families. 

Per  Ctnt.* 



i 

179 
173 
91 
71 
34 
24 
17 
17 
8 
17 
9 

None 

12.4 

One,   — 

24.4 

23.7 

Thrpp 

12.4 

Five  '  "'                                    —    -    

9.7 
4  7 

Six,        

'3.3 

2.3 

Eight                    -             — 

2.3 

Nine,       __      

1.1 

Ten                                                                         _       _ 

2  3 

Over  ten, 

1.2 

Total 

740 

100  0 

•Based  on  the  731  families  about  which  this  information  was  available. 
F — Member  of  Family  111. 


Person. 

- 

Number 
of  Cases. 

Per  Cent.* 

No  information, 

5 
527 
319 
465 

077 

Principal  wage  earner,  ,_      

26.5 

16.0 

Housekeeper, 

23  4 

All  others, 

84  0 

Total, 

1,994 

100  0 

*Ba8ed  on  the  1,989  cases  for  which  this  information  was  available. 
G — Duration  of  Cases  of  Illness* 


Length  of  Illness. 

Number 
of  Cases. 

Per  Cent. 

1—  2  weeW  ----I--~'--------"I"I------~--"" 

2—  3  weeks,   

3—  4  weeks,  

194 

351 

219 

85 

283 

97 

65 

178 

13.2 
23.9 

14.8 
6  7 

1—  3  months,   

3—  6  months,   , '_ 

6 — 12  months, _  _ 

19.2 
6.6 
4  5 

12  months  and  over, ^ 

12.1 

Total 

1.472 

100.0 

*Pssed  on  the  1,422  eases  in  which  this  information  was  obtained, 


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74 

Part  II,   Section  I,  Table  V. 

NUMBER  OF  PENSONS  ENUMERATED.  NUMBER  OP  CASES  OF  SICK- 
NESS. RATES  OF  SICKNESS  PER  1,000  EXPOSED.  METROPOLI- 
TAN LIFE  INSURANCE  COMPANY  POLICY  HOLDERS.  PRINCIPAL 
DISTRICTS  IN  WESTERN  PENNSYLVANIA. 


State  and  District. 


White  Persons. 


Colored  Persons. 


Pennsylvania ,/    

308,009 

5,390 

17.5 

20,042 

417 

20.8 

Pittsburg-h,     

115,618 
15,866 
14,798 
15,906 
11,561 

2,767 
'22,408 

4,855 
25,325 

1,589 
45,945 
11,486 

5,579 
11,034 

3,272 

1,869 
248 
288 
"51 
257 

52 
404 
105 
531 

S3 
814 
186 

96 
207 

58 

16.2 
15.6 
19.5 
15,8 
22.2 
18.8 
18.0 
21.6 
21.0 
20.8 
17.7 
16.2 
17.2 
18.8 
17.7 

12,049 

1,199 

1,199 

48 

2.366 

613 

406 

96 

188 

4 

230 

317 

214 
28 
37 
2 
66 
15 
17 

17.8 

Braddock,    _ 

23.4 

McKeesport,   _      _  _ 

24.1 

Pottsville,   

• 

27.9 

Connellsville,   

• 

• 

7 

1 
5 
9 

• 

Shamokin 

• 

Wilkes-Barre,           - -    

* 

» 

TTa7lptnn 

ShpnandOiah 

'Wflshino+.OTi                                                _  _ 

992 

16 

• 

^Insu£Qcient  data. 


75 

Part  II,  Section  I,  Table  VI. 

NUMBER  OF  CASES  OF  SICKNESS  AND  RATES  PER  1,000  EXPOSED, 
TOTAL  SICK,  AND  SICK  PERSONS  UNABLE  TO  WORK  CLASSIFIED 
BY  AGE  AND  BY  SIX.     PITSBURG  SICKNESS  SURVEY. 


. 

i 
§ 

o 

1^ 

Total   Sick 

Persons. 

Sex  and  Age  Period. 

1 
1 

All  Persons: 

All  ages,   __ 

115,618 
75,714 

1,869 
1,631 

16.2 

15  years  and  over,   

20.2 

Under  15,    ^ 

15  to  24,  

25  to  34, 

39,761 

20,103 

20.263 

16,521 

10,784 

5,555 

2,488 

143 

335 
205 
325 
315 
283 
218 
"  185 
3 

8.4 
10.2 
16.0 

35  to  44,  

19.1 

45  to  54,  

26.2 

55  to  64,  

39.2 

65  and  over,  _. 

74.4 

Unknown  age,  

Males: 

All  ages, —      

56,615 
36,760 

952 

781 

16.8 

15  years  and  over,  _    

21.3 

Under   15,        _     _ 

19,792 
9,538 
97847 
8,284 
5,331 
2,659 
1,101 
63 

169 

92 
154 
165 
162 
118 

90 
2 

8.5 

15  to  24,            _      __ 

9:6 

25  to  34,  

15.6 

35  to  44,  -_■_ 

19.9 

45  to  54,   

30.4 

55  to  64, _. 

44.4 

81.7 

Unknown  age. 

Females: 

59,003 
38,954 

917 
750 

15.5 

15  years  and  over. 

19.3 

UDder  15,  

15  to  24,          

18,969 

10,565 

10,416 

8,237 

5,453 

2,896 

1,387 

60 

186 
113 
171 
150 
121 
lOO 
95 
1 

8.3 

10.7 

-25  to  34,  

35  to  44 

16.4 
18.2 

45  to  54                 ...     

22.2 

55  to  64,  

65  and  over,  

Unknown  age,  

34.5 
68.5 

76 


Part  II.   Section  1,   Table  VII. 

NUMBER    OF    CASES,    RATES    PER    1,000    EXPOSED.      CLASSIFIED 
EXTENT  OF  DISABILITY,    SEX  AND  AGE  PERIOD. 
WESTERN  PENNSYLVANIA  SURVEY    (i). 


BY 


State  of  Pennsylvania. 

" 

■ 

a 
1 

Total  Sick  Persons. 

Sick,  Unable  to  Work. 

Sex  and  Age  Period. 

§ 

Number. 

Pter      1,000      ex- 
posed. 

Males: 

All  ages,  

Ages  15  and  over, 

Under  15,    

15  to  24,   

25  to  34,    

35  to  44,   

45  to  54,    - 

55  to   64,    

65  and  over,   . 
Unknown   age, 

Females: 

All  ages,   

Ages  15  and  over. 

Under  15,   ___. 

15  to  24,   

25  to  34,   

35  to  44,   

45  to  54,    

55  to  64,    

65  and  over,  . 
Unknown  age. 


153,440 
97,387 


55,887 
25,989 
26,223 
21,848 
13,679 
6,891 
2,757 


154, 

96, 


55,827 

28,011 

26,834 

20,236 

12,979 

7,113 

3,395 

174 


2,823 
3,314 


504 
3[>2 
393 
464 
508 
379 
268 
5 


2,576 
2,069 


504 
334 
424 
410 
355 
270 
276 
3 


18.4 


9.0 
11.6 
15.0 
21.2 
37.1 
55.0 
97.2 


16.7 
21.0 


9.0 
11.0 
15.8 
20.3 
27.4 
38.0 
81.3 


2,654 
2,151 


421 
459 
352 


,430 


491 
318 
403 
375 
326 
246 


17.3 
23.1 


11.1 
14.1 
19  3 
33.6 
51.1 
95.0 


15.7 
19.6 


8.8 
11.4 
15.0 
18.5 
25.1 
34.6 
78.9 


(1)  Figures  for  white  persons  only. 


77 

Part  II,   Section  I,  Table  VIII. 
SICKNESS  RATES  BY  AGE  AND  SEX.     PHILADELPHIA  SURVI^Y, 


All  Persons. 

Males. 

Females. 

Total. 

Unable 
to  Work. 

Total. 

Unable 
to  Work. 

Ttatal. 

Unable 
to  Work. 

All  persons,   

15     years      and 
over, 

4.280 

5.335 
2.196 
2.669 
4.358 
5.280 
7.293 
9.338 
12.658 
2.041 

1.573 

1.958 
814 
1.626 
1.533 
1.674 
2.370 
3.501 
5.379 
.816 

4.252 

5.242 
2.246 
3.163 
4  202 

1.714 

2.190 

749 

1.734 

4.301 

5.431 
2.147 

4.092 
4.523 
5.042 
6.614 
10.975 
11.173 
1.666 

1.428 

1.717 

878 
1.535 
1.672 
1.40O 
1.945 
2.03;i 
3.911 

Under  15,  

15-24, 

25-34,    __.     

35-44    

5.482  !                1.907 
7.890  i                2.744 
7.835                  4.850 
14.598                  7.299 
2.162  1                1.081 

45-54,  

56-64,   

65  and  over, 

Age  unknown,  — 

J 


Part  II,    Section  1,  Table  IX. 
SICKNESS  RATE  PER  100  BY  DISTRICTS.     PHILADELPHIA  SURVEY. 


Nationality. 


Rate  Per  100. 


1.  Jewish,  Polish,  Austrian, 

2.  Italian,    

3.  Negro,    

4.  Negro, 

5.  Negro,    .-* 

6.  Irish,   American,   Polish,   

7.  American,   negro,   

Average   for   districts   covered 


3.877 
S.231 
4.447 
9.302 
3.874 
4.867 
4.034 


78 


79 

Part  II,  Section  I,  Table  XI. 

DISTRIBUTION  OF  10,000  CASES  OF  SICKNESS  AND  NON-INDUSTRIAL 
ACCIDENTS   FOR   EACH   OF   TEN   BENEFIT   ASSOCIATIONS  (i). 


Duration  in  days. 


No.  1. 

Ho.  2. 

No.  3. 

No.  4. 

5,573 

4,612 

4,474 

4.276 

i,8au 

:i,03i 

1,690 

1,828 

TO) 

946 

893 

924 

415 

553 

68a 

616 

290 

346 

326 

445 

203 

252 

336 

313 

15<j 

192 

2<3 

215 

120 

U6 

210 

139 

»U 

109 

95 

115 

72 

84 

116 

105 

55 

73 

lU) 

185 

54 

6/ 

88 

iS> 

33 

57 

66 

60 

40 

49 

62 

47 

37 

37 

55 

40 

21 

34 

46 

33 

22 

31 

35 

71 

15 

22 

31 

25 

12 

20 

22 

24 

13 

17 

28 

19 

10 

15 

20 

18 

9 

14 

19 

19 

12 

12 

18 

18 

t> 

10 

1^ 

16 

.7 

9 

16 

16 

7 

11 

15 

14 

132 

249 

260 

390 

No.  5. 


No.  6. 

No.  7. 

No.  8. 

No.  9. 

2.510 

2.383 

3,306 

2,384 

2,043 

1,937 

1.911 

2,272 

1,293 

1,491 

1.021 

1,280 

b'jj 

783 

599 

786 

(09 

533 

434 

448 

43/ 

609 

362 

433 

359 

468 

308 

357 

2/6 

186 

217 

280 

226 

294 

209 

188 

166 

174 

143 

173 

164 

98 

115 

137- 

161 

141 

126 

132 

111 

98 

99 

87 

112 

65 

82 

102 

79 

44 

104 

66 

67 

44 

38 

61 

71 

33 

66 

51 

35 

44 

49 

46 

50 

11 

60 

46 

33 

22 

55 

66 

38 

53 

25 

31 

21 

33 

33 

41 

21 

0 

44 

36 

15 

11 

33 

15 

27 

22 

29 

31 

20 

11 

33 

51 

67 

413 

439 

392 

NO.  10. 


8-  14. 

15-  21, 

ZZ-  28. 

29-  35, 

36-  42. 

43-  49. 

50-  56. 

5<-  63. 

64-  70, 

VI-  77, 

78-  84, 

85-  91. 

92-  98. 

99-105, 

106-112. 

113-119. 

lia>-126. 

127-133, 

134-140. 

141-147, 

145  154. 

155-161, 

162-168. 

169-175, 

176-182, 

183-189, 

190,    


3,472 

l,a4 

1,176 

791 

602 

3i^ 

33/ 

240 

205 

164 

135 

127 

100 

60 

45 

34 

66 

25 

22 

20 

17 

16 

15 

13 

13 

12 

221 


1.610 

2.260 

1,520 

9»6 

714 


294 
219 
1&3 
152 
U9 
108 
93 
86 
67 
34 
33 
37 


30 
11 
22 
15 
8 
616 


DURATION  PERCENTAGE. 


8  days. 

No.  1. 

No.  2. 

No.  3. 

No.  4. 

No.  5. 

No.  6. 

No.  7. 

No.  8. 

No.  9. 

No.  10. 

Totel. 

2   weeks. 

55.73 

46.12 

44.74 

42.76 

34.72 

25.10 

23.83 

33.66 

23.84 

16.10 

34.56 

2-4    wks.,- 

26.00 

29.77 

25.83 

27.52 

28.90 

33.36 

34.28 

29.32 

35.61 

37.80 

30.83 

1  o   mo.  ,„ 

14.51 

18.24 

22.33 

22.08 

29.95 

33.87 

32.85 

25.13 

29.33 

34.91 

26.42 

3f/  ino.._- 

2.37 

3.27 

4.35 

4.06 

4.46 

6.80 

4.80 

7.17 

6.79 

5.95 

6.00 

Qvex        6 

mo.,    _. 

1.39 

2.60 

2.75 

4.04 

2.33 

.87 

4.24 

4.72 

4.43 

5.24 

3.28 

(1)  Distribution  No.  7  is  the  combination  of  the  distributions  given  by  three  relatively  small 
associations,  each  of  which  is  orgranized  and  administered  in  such  a  way  as  to  give 
trustworthy  results.     The  actual  number  of  cases  used  in  forming  No.  7  was  919. 


80 

Part  II,  Section  I,  Table  XII. 

SEPARATE  DISTRIBUTION  OF  10,000  CASES  EACH  OF  SICKNESS  AND 
NON-INDUSTRIAL  ACCIDENTS  FOR  MEN.  FOR  WOMEN,  AND  FOR 
MEN  AND  WOMEN  AS  DETERMINED  BY  THE  DATA  FROM  AN  IM- 
PORTANT BENEFIT  ASSOCIATION. 


Duration   in   Days. 

Males. 

Females. 

Males 

and 

Females. 

8   14 

15-  21,   __ _      __ 

4.098 

1,988 

908 

564 

368 

245 

221 

243 

209 

147 

86 

86 

49 

74 

37 

26 

74 

37 

25 

61 

12 

i 

25 
37 
37 

294 

2,773 

1,849 

1,113 

626 

487 

457 

378 

199 

209 

139 

1S9 

159 

139 

89 

159 

50 

60 

60 

88 

50 

30 

40 

60 

40 

20 

30 

557 

3,366 
1,911 

22-  28,   

29-  36,   

1.021 
590 

?7-  42, 

4Si 

43-  49.   

30i 

50-  56.   

57-  63,   ._ 

306 
217 

64-  70. 

209 

71-  77,  

143 

78-  84,          

115 

85-  91,   

126 

92-  98        

96 

99-105,  

82 

106-112,   - 

113-119, 

104 
S8 

120-126 _      —    _          —    _                         .     . 

66 

127-133 

49 

134-140,       —      

60 

141-147,  

Sis 

148-154     _              _-            

25 

155-161.   ^ 

33 

162-168,              _              —     —      '..      

44 

169-175.   

176-182                       -          

83 
29 

183-189    

33 

439 

Total         -      -      - - - 

10,000 
815 

10,000 
1,006 

10,000 
1.821 

The  actual  number  of  cases  for  men,  for  wx)men,  and  for  men  and  women  used  In  forming 
the  table  were  815,  1,006,  and  1,821,  respectively. 


Part  II,   Section  I,  Table  XIII. 

PENNSYLVANIA   RAILROAD    (EAST) ,    VOLUNTARY   RELIEF   DEPART- 
MENT,   1913-1917. 

Number  and  duration  of  completed  cases  of  sickness  and  non-industrial  accident 
tabulated. 


Duration. 

Number 

of 
Gases. 

Per  cent. 

Actual 
Duration 
in  Days. 

4  days— 2  weeks, _ 

2  weeks--4  weeks.  

1  month — 3  months,  -           -        - 

48,198 

9,782 

5,416 

920 

356 

177 

74.3 

15.0 

8.3 

1.4 

.54 

.27 

365.987 
191.397 
257.754 
111,090 
88.820 
152.231 

6  months — 1  year,  

Over  1  year, 

Total.    : 

64,849 

99.81 

1.167,279 

81 


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82 


Part  II,    Section  I,    Table  XV. 

MORTALITY  IN  THE  GENERAL  POPULATION  OF  PENNSYLVANIA, 
TO    1916.     DEATH   RATES    PER   100,000. 


1906 


Area.     Year. 

All 
Causes. 

Typhoid 
Fever. 

Tubercu- 
losis of 
Lungs. 

Diarrhoea 

and  (1) 

Enteritis. 

Accident. 

Registration  area  (1916), 

Total  State  of  Pennsylvania: 
1916 

1,398.9 

1,461.8 
1,376.0 
1,392.6 
1,455.3 
1,403.3 
1,421.0 
1,557.3 
1,469.9 
1,513.2 
1,593.0 
1,602.3 

1,594,1 
l,48r.6 
1,530.6 
1,565.3 
1,510.9 
1,548.5 
1,688.7 
1,679.2 
1,648.3 
1,771.8 
1,803.6 

1,339.1 
1,270.9 
1,265.2 
1,354.0 
1,304.6 
1,304.6 
1,437.5 
1,377.2 
1,399.1 
1,442.3 
1,438.7 

13.3 

13.6 
12.3 
13.0 
18.6 
16.4 
21.9 
24.6 
22.7 
33.0 
48.6 
54.8 

13.6 
12.5 
13.4 
20.2 
16.5 
23.8 
25.1 
-24.9 
39.0 
67.0 
76.7 

13.5 

12.2 

12.6 

16.2 

16.4 

20.2 

24.2 

20.8 

28.0 

33.1^ 

38.4 

123.8 

112.3 
110.6 
107.2 
104.5 
108.3 
117.9 
117.0 
115.1 
117.3 
1J28.0 
129.6 

126.8 
124.4 
124.7 
122.4 
126.9 
140.7 
140.1 
140.1 
145.2 
158.4 
164.8 

98.9 
97.8 
91.2 
88.1 
91.1 
97.0 
96.1 
94.0 
93.8 
102.4 
lOO.O 

65.6 

101.7 

90.7 

95.4 

106.3 

93.7 

>     104.1 

144.0 

130.9 

140.1 

137.0 

157.5 

105.3 
95.7 
105.7 
111.5 
103.1 
118.4 
156.8 
141.5 
151.0 
155.4 
176.9 

96.3 

86.0 

85.9 

101.5 

85.1 

91.1 

132.4 

121.8 

130.9 

121.4 

141.1 

90.9 
1(X7.8 

1915.    

92.6 

1914.    

94.2 

1913,        _      _' 

105.2 

I&IO,    ""-          1-1-  '      _  _      - 

102.2 
106.2 
107.1 

1900.    

1908,    

108.4 
116.5 

1907. 

137.0 

190S,    

131.6 

Urban. 

1916 - 

113.0 

1915, 

94.4 

1914,                  _           

97.6 

1913,    

104.1 

1912,    

1911, 

104.2 
105.7 

1910,    _„ 

111.5 

1909, 

106.7 

1908 

1907.    

1906.    .-^ .-— 

Rural: 

1916,   

1915.   

1914,    -  -               _          _             -  _    - 

108.6 
132.4 
135.6 

102.9 
91.0 
96.7 

1913,    

1912,    

106.3 
10O.5 

1911 __- 

1910,    

106.6 
103.1 

1909, 

106.2 

1907,    

its.s 

140.4 

1906, 

128.1 

(1)  "All  ages,"  1906-1909;  "under  2  years"  after  1909. 

(2)  Includes  Allegheny  after  1907. 

(»)  Included  in  Pittsburgh  after  1907. 


S3 


Part  II,  Section  I.  Table  XVI. 

MORTALITY  IN  THE  GENERAL  POPULATION  OF  PENNSYLVANIA, 
TO  1916.     DEATH  RATES  PER  100,000. 


1906 


Area.     Year. 


Philadelphia: 

1916,    

1916 

1914,    

1913 

1912,    

1911,    

1910,  — 

1909,    

1908 _ 

1907,    

1906,    

Pittsburgh: 
1916, i- 

1915,    

1914,    

1913 

1912 -_ 

1911,    

1910,    

1909,    

1908,    

1907,  .'- . 

1906,    

(») 
Allegheny: 

1907,    

1906,    

Scranton: 

1916,    

1915 __. 

1914,    . 

1913,    

1912,    

19U,    

1910,    

1909 

1908,    

1907,    

1906.    

Wilkes-Barre: 

1916,    

1915 

1914,    

1913,    

1912,    

1911,    

1910.    

1900,    

1908,    

1907,    

1906,    


All 
Causes. 


,620.5 
,561.5 
,612.9 
,569.4 
,528.2 


,637.4 
,725.3 

,860.5 
,913.7 


,740.1 
,525.9 
,567.9 
,712.2 
,591.2 
,493.0 
,793.7 
,579.3 
,732.6 
,929.0 
,990.0 


1,939.2 
1,980.8 


1,441.3 
L, 467.2 
L, 578.3 
1,483.9 


1 

1 

1 

1 

1,482.2 

1,482.8 

1,640.7 

1.629.2 

1 

1 

1 


1,640.4 
,574.4 
[,641.6 


,447.1 
,615.3 
,535.4 
,510.4 
,501.2 
,553.9 
,656.5 
,551.5 
,550.2 
,671.6 
.4«9.0 


Typhoid 

Fever. 


7.6 
6.8 
7.6 
15.7 
12.8 
14.6 
17.5 
22.3 
35.2 
60.3 
74.3 


9.0 
10.3 
15.0 
19.5 
13.1 
25.6 
27.8 
24.6 
48.9 
131.2 
141.1 


108.7 
150.7 


6.1 
12.5 
9.2 
9.4 
10.3 
14.3 
16.9 
16.4 
11.2 
75.2 
61.0 


16.6 
10.6 
6.8 
12.5 
17.0 
11.6 
37.1 
13.7 
23.3 
44.6 
31.0 


Tubercu- 
losis of 
Lungs. 


170.6 
164.3 

i6r.7 

165.0 
170.2 
193.6 
193.5 
189.0 
201.7 
220.8 
225.1 


110.7 
108.4 
109.2 
106.5 
100.4 
106.0 
104.2 
109.0 
114.2 
112.4 
126.2 


145.9 
176.6 


74.2 
72.2 

78.4 
78.5 
75.8 
99.9 
90.5 
84.6 
80.0 
81.7 
71.9 


89.1 
66.5 
61.3 
83.6 
84.1 
71.2 
89.6 
69.1 
79.7 
70.3 


Diarrhea 

and  (1) 

Enteritis, 


88.3 

90.0 
107.4 
100.6 

93.4 
118.0 
160.3 
129.6 
137.6 
147.3 
172.0 


117.8 
97.6 
103.7 
134.8 
113.5 
130.3 
177.3 
156.9 
182.7 
209.2 
230.0 


181.6 
194.1 


141.7 
138.7 
162.7 
138.5 
163.8 
173.6 
230.8 
230.2 
207.1 
183.9 
85.6 


146.2 

91.0 

88.8 

93.6 

131.9 

135.0 

118.4 

158.6 

159.3 

114.4 


Accident. 


91.5 
70.7 
74.7 
78.2 
79.2 
89.2 
83.6 
85.4 
90.0 
103.5 
100.1 


134.2 
109.8 
109.6 
136.3 
112.8 
106.6 
134.3 
124.4 
114.6 
164.7 
190.6 


166.8 
1ST.9 


138.3 
130.5 

isr.i 

167.  S 
147.2 
177.3 
167.1 
187.1 
181.6 
183.0 
188.9 


181.0 
190.1 
184.6 
134.6 
182.9 
207.3 
225.4 
195.8 
225.5 
267.7 
220.6 


(»)  "All  ages,"  1908-1909;  "under  2  years"  after 
(2)  Includes  Allegheny  after  1907. 
(8)  Included  in  Pittsburgh  after  1907. 


84 

Part  II,    Section   I,    Table   XVII. 

METROPOLITAN  LIFE  INSUPANCE  COMPANY,   INDUSTRIAL  DEPART- 
MENT,   STATISTICS   FOR   PENNSYLVANIA. 

Claim   rates   per   1,000,    by   color.      Principal   districts   in   state,    1915,    1916, 
1917(1). 


Area. 


Total  State  of  Pennsylvania, 


Allentown,    

Braddock,   

Bristol,     

Chester,    

Ooatesville,  

DuBois,  

Easton,  

Erie,  

Harrisburg,    

Hazleton,  

Johnstown,  

Lancaster,  

McKeesport,   

Millvale,    

New  Oastle,  

New  Kensington,  _„ 

Norristown, 

Philadelphia   (total), 

Pairmount,  

Frankford,   .— 

Germantown,  

Girard,    

Harrowgate,    

Kensington,    

Manayunk,   

Middle,  

Nicetown,  

Schuylkill,    

Shackamaxon,    

South,    

Southwark,  

West,   

Pittsburgh   (total), 

Pittsburgh,    _. 

Allegheny,    

East  Liberty, 

South 

Pottstown,   

Pottsville,   

Reading,  

Scranton,  

Shenandoah,    

Uniontown,     

Wilkes-Barre,  

Willi  amsport,    

York.   


White. 


1917 


12.4 


1916 


12.5 


10.6 
10.6 
10.4 
11.6 
10.2 

7.9 
11.4 

7.8 
12.4 
13.1 

9.6 
10.4 

9.3 
10.9 
11.7 

7.8 
11.4 
13.6 
12.9 
12.9 
10.9 
16.7 
13.2 
14.0 
12.2 
12.9 
12.1 
12.0 
15.8 
16.4 
14.4 
12.6 
11.8 
14.6 
12.4 
11.6 

9.5 
11.4 
16.5 
12.8 
14.4 
19.8 

9.7 
14.6 
10.3 

8.1 


1916 


11.2 
9.9 


10.8 
6.0 
9.4 
16.2 
6.2 
9.2 
13.9 
9.3 
10.8 
9.3 
9.3 
9.7 
5.9 
11.5 
13.1 
12.9 
11.0 
10.7 
13.6 
13.6 
15.0 
12.8 
13.8 
11.1 
12.9 
16.1 
15.3 
14.1 
11.9 
11.0 
12.5 
12.3 
10.2 
9.5 


14.0 
11.7 
13.8 
16.3 
7.9 
13.1 
9.9 
8.1 


Colored. 


1917 


15.7 


22.2 
14.7 

4.4 
15.1 
12.8 

9.4 
23.1 
24.3 
17.7 


15.2 
11.3 
16.7 

7.8 
10.7 
13.4 
14.7 
16.4 
22.9 
12.9 
13.2 
17.0 
22.4 
20'.  0 

9.5 
12.7 
13.2 
13.4 
16.5 
18.5 
20.5 
14.2 
16.3 
18.8 
17.4 
14.1 
14.4 

8.1 

6.3 
14.6 

9.0 


1916 


15.9 
12.1 
18.4 

24.8 


16.6 


19.7 
16.9 
24.4 
16.6 
16.7 
28.2 
3.4 
5.0 
15.5 


16.6 
18.3 
11.7 
20.1 
19.9 
16.6 
13.8 
15.0 
10.5 
17.6 


16.8 
12.7 


13.9 
8.1 
9.2 
16.8 
26.4 
16.2 
22.3 
11.7 
16.0 
16.3 
18.4 
15.5 
14.6 
9.6 
21.6 
34.4 
10.0 


16.7 
24.1 
10.9 
15.0 


1915 


15.4 


18.9 
17.3 


18.9 
15.3 


8.6 
23.5 
25.2 


21.5 
10.8 
13.3 

7.6 
18.0 
12.6 
12.4 
14.5 
10.5 
23.3 
11.7 
16.0 
46.0 
20.4 

8.5 
21.5 
16.6 
12.6 
17.1 
14.0 

IsTtx 
14.6 
14.1 
15.6 
16.0 
.12.7 


52.2 
15.2 
6.9 


17.6 
23.0 
20.1 
14.6 


(1)  The  number  of  policy  holders  in  Pennsylvania  is  unknown;  approximately  70  per  cent,  of 
the  number  of  policies.  The  claim  rate  per  1,000  must  be  interpreted  in  the  light  of  varying 
sex  and  age  characteristics  of  the  several  groups. 


Part  II,    Section  I,    Table  XVIII. 

Claims  and  claim  rates  per  100,000  policies.     State  of  Pennsylvania,   1917  by 
color. 


Cause  of  Death. 


White. 


Claimfi. 


Claim 
Rate. 


Colored. 


Claims. 


Claim 
Bate. 


All  causes  of  death, 


Typhoid  fever,   

Communicable    diseases    of    childhood:    Measles, 
scarlet  fever,   whooping  cough,   diphtheria  and 

croup, 

Tuberculosis  of  the  lungs,   

Other  forms  of  suberculosis, 

Cancer,  all  forms,  

Cerebral  hemorrhage  and  softening  of  the  brain 

Organic  diseases  of  the  heart, 

Bronchitis,     _-. 

Pneumonia,  all  forms, 

Diarrhea  and  enteritis  (under  2  years  of  age), 

Acute  nephritis  and  Bright's  disease,  

Puerperal  state,  

External  causes— including  suicide,   


18.094 


135 


1,244.4 


9.3 


435 

29.9 

2,212 

152.1 

177 

12.2 

1,294 

89.0 

1,229 

84.5 

2,479 

170.5 

196 

13.5 

2,165 

148.9 

125 

8.6 

1,885 

129.6 

293 

20.2 

1,580 

108.7 

28 


1,569.2 


17.7 


43 

27.2 

499 

315.3 

53 

33.6 

108 

68.3 

106 

67.0 

298 

188.4 

22 

13.9 

374 

286.4 

16 

10.1 

224 

141.6 

.% 

22.1 

157 

99.3 

Part  II,    Section  I,  Table  XIX. 

INFANT  MORTALITY  AMONG  ALL  CHILDREN  OF  MARRIED  MOTHERS 
INCLUDED  IN  JOHNSTOWN  INVESTIGATION  BY  FATHER'S  AN- 
NUAL EARNINGS. 


Father's  Annual  Earnings. 

Infantile  Mortality 

Rate  (Deaths 

Under  1  Year  per 

1,000  Births). 

Under  $521,   

197.3 

$521—    684,     

193.1 

$625 —    779, —     _  _      __      _- 

163.1 

$780—    899;     

168.4 

$900—1,199,     _ 

142.3 

$1,200  and  over,  

102.2 

86 


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PART  II. 

SECTION  II. 

Losses  Due  to  Sickness. 


(87) 


(88) 


8i) 

LOSSES  TO  EMI^LOYEES. 

The  chief  losses  to  employees  from  sickness  embrace  their  loss 
of  time  and,  consequently,  of  wages  during  absence  from  work  on 
account  of  sickness ;  the  cost  of  medical  care  for  themselves  and  their 
dependents,  and  the  possible  loss  of  future  working  power.  To  form 
any  judgment  on  the  seriousness  of  such  losses,  ift  is  necessary  first 
to  get  an  idea  of  the  economic  status  of  the  employees  in  Pennsyl- 
vania, their  wage-rates,  the  amount  of  unemployment,  and  the  mini- 
mum cost  of  healthful  living. 

The  present  is  a  peculiarly  difficult  time  to  secure  any  such  facts. 
Wage  readjustments,  especially  in  the  many  war  industries  of  Penn- 
sylvania, are  frequent,  while  the  cost  of  living  is  rising  to  record 
heights.  An  attempt  will  be  made  to  give  very  briefly  the  situation 
in  1914,  just  before  the  European  war,  which  may  be  regarded  as 
comparatively  normal.  The  wage  rates  for  1916,  compiled  especially 
for  the  Commission  by  the  Department  of  Labor  and  Industry,  have 
been  used  to  suggest  the  earlier  effects  of  the  European  war,  and 
certain  facts  have  been  gathered  on  recent  changes  since  America 
entered  the  conflict.  ** 

The  1914  wage  statistics  published  by  the  Department  of  Labor 
and  Industry  covered  20,571  establishments  in  the  various  forms  of 
manufacturing,  the  building  trades,  and  "horticultural  and  floricul- 
tural  products."  A  comparatively  small  number  of  "mines  and  quar- 
ries", excluding  coal  mines,  were  also  included.  The  average  yearly 
wage  for  all  males  was  |720,  or  |14.40  a  week.  The  lowest  wage, 
.f323,  was  found  in  "engineering  and  laboratory  service,"  but  this 
covered  ^nly  a  few  establishments.  Next  came  "mines"  with  |469 — 
I)robably  at  this  low  level  because  of  the  amount  of  slack  time — and 
"tobacco  and  its  products,"  with  |512.  The  highest  annual  wages, 
|1,002,  were  received  in  "liquors  and  beverages,"  and  the  "printing 
trades"  were  second  with  $865.  The  average  annual  wage  for  all 
females  was  |335,  slightly  over  |6  a  week,  with  somewhat  less  strik- 
ing variations  from  trade  to  trade  than  was  the  case  with  males. 
For  boys  under  sixteen  it  was  |224  and  for  girls  of  the  same  age, 
|191.    The  average  for  all  "salaried  and  office  help"  was  |1,207.^ 

A  joint  investigation  by  the  Consumers'  League  of  Eastern  Penn- 
sylvania and  the  State  Department  of  Labor  and  Industry,  of  the 
wages  of  women  in  five  Philadelphia  department  stores,  carried  on 
between  November  15,  1913,  and  June  15,  1914,  showed  that  in  this 
occupation  16.5  per  cent,  of  the  women  received  less  than  |5  a 
week,  63.8  per  cent,  more,  between  |5  and  |10,  and  only  3.2  per  cent. 
|15  or  over. 

4114 

No  figures  could  be  obtained  for  the  wages  of  farm  help,  but  the 
present  shortage  of  farm  labor  has  emphasized  the  fact  that  they 
range  lower  than  in  the  factories. 

(i)Se€  Table  II  at  the  end  of  this  section. 


90 

The  "average  annual  wages"  make  allowance  for  reduction  for 
unemployment  which,  it  will  be  remembered,  was  especially  pre- 
valent in  1914.  An  unemployment  census  of  Metropolitan  Life  In- 
surance Company  policy-holders  in  Philadelphia  indicated  that  there 
were  in  the  city  at  that  time  79,000  persons  out  of  work-  and  150,000 
more  on  part  time,  or  about  30  per  cent,  of  all  wage-earners.  This 
was,  of  course,  the  result  of  "hard  times,"  but  Mr.  Joseph  H.  Willitts, 
discussing  these  and  other  figures  on  the  extent  of  unemployment  in 
Philadelphia,  stated  that  normally  much  unemployment  and  part-time 
employment  were  to  be  found  in  the  principal  industries  such  as 
textiles,  clothing  and  railroad  equipment,  due  to  the  increasing  tend- 
ency to  manufacture  only  on  order.^ 

The  same  factor  making  for  irregular  employment  is  evident  under 
ordinary  peace-time  conditions  in  the  iron  and  steel  industry  in  the 
western  part  of  the  state.  The  dependence  of  the  coal  miners  on  the 
supply  of  cars  is  likewise  well-known.  It  is  commonly  estimated 
that  they  normally  have  work  for  about  two-thirds  of  the  time. 

Food  prices  had  not  in  1914  begun  their  present  rapid  increase 
but  had  risen  slowly  about  25  per  cent,  since  1907,  so  that  the  average 
wage,  |2.40  a  day,  in  1914  was,  in  terms  of  the  cost  of  food,  equivalent 
to  less  than  |2  a  day  in  1907. 

From  figures  supplied  by  the  Department  of  Labor  and  Industry, 
a  special  compilation  was  made  of  the  percentage  of  wage-earners  in 
various  wage-groups  in  1915  for  the  following  leading  industries  of 
the  state — building  and  contracting,  textiles,  metal  products  (pre^ 
paration  of  raw  materials),  metal  products  (finished  products),  and 
anthracite  and  bituminous  coal.  ^  In  these  industries,  only  a  sixth 
of  the  males  covered  received  less  than  |15.  Wages  seemed  to  be 
somewhat  above  the  average  in  the  bituminous  coal  industry,  where 
32.0  per  cent,  had  weekly  wages  between  $15  and  |18.  They  were 
especially  low  in  the  textile  industries,  in  which  50.2  per  cent,  of 
the  males  earned  less  than  |12  a  week.  The  latter  was  the  only  one 
of  this  group  of  industries  in  which  large  numbers  of  females  were 
employed,  five-eighths  of  whom  received  between  |5  and  $10  a  week. 

During  1915  and  1916,  the  industrial  depression  was  succeeded 
by  a  boom  in  the  many  Pennsylvania  establishments  having  war 
contracts  for  the  Allies,  and  the  average  daily  wage  for  males  in 
the  industries  covered  by  the  Production  Report  of  the  Department 
of  Labor  and  Industry  was  slightly  higher  in  1916  than  in  1914, 
12.76  instead  of  |2.40.^'  For  females  the  rise  reported  was  from  fl.ll 
to  |1.30.  In  the  latter  year,  "steam  railways,"  and  "street  railways" 
were  included  in  a  "public  service"  classification  which  was  added  to 
the  list  of  occupations  covered.    The  average  daily  wage  of  males  in 

(1)  Annals  of  the  American  Academy  of  Political  and  Social  Science,  Supplement,  May  1918, 
pp.  1-35. 

(2)  See  Table  III  at  the  end  of  this  section. 
(8) See  Table  I  at  the  end  of  this  section. 


91 

this  group  was  |2.56.    Variations  between  the  different  trades  were 
simihir  to  those  in  1914, 

The  entrance  of  the  United  States  into  the  war,  feverish  activity 
in  all  war  industries,  many  wage  readjustments,  including  some  by 
^specially-formed  government  boards,  along  with  a  never-ceasing  rise 
in  the  cost  of  living,  are  the  chief  features  affecting  the  economic 
fetatus  of  the  employees  of  the  state  during  the  past  year  and  a  half. 
It  is  probable  that  any  gain  in  the  real  wages  of  employees  during 
the  period  is  rather  the  result  of  steadier  work  and  of  overtime  than 
of  higher  wage-rates.  Wages  in  the  ship-building  yards  were  fixed 
by  the  Shipbuilding  Labor  Adjustment  Board  on  March  1,  1918,  at 
about  sixty  to  seventy-five  cents  an  hour  for  skilled  craftsmen,  forty- 
five  cents  for  helpers,  and  thirty-five  cents  for  common  laborers, 
with  time  and  a  half  for  all  overtime  between  forty-four  and  sixty 
hours  a  week.  This  means  about  $30  a  week  for  the  skilled  man, 
|20  for  the  helper  and  |16  for  common  labor,  with  the  possibility  of 
$15,  |10  or  $S  more  for  overtime.  The  railway  wage  increase  dating 
from  January  1,  1918,  applied  to  employees  of  railroads  in  Pennsyl- 
vania as  well  as  in  other  sections,  and  provided  graduated  increases 
of  from  43  per  cent,  for  those  earning  |50  a  month  or  less,  to  nothing 
for  those  earning  |250  or  more.  In  1916  and  1917  five  increases  total- 
ling 60.6  per  cent,  have  been  granted  in  the  iron  and  steel  industry 
The  organized  anthracite  coal  miners  sought  and  obtained  a  raise 
of  10  per  cent,  in  the  spring  of  1917  on  the  ground  of  the  increased 
cost  of  living.  A  previous  7  per  cent,  increase,  in  1916,  was  the  first 
since  1912. 

No  student  of  wages  is  surprised  at  these  low  figures.  After  a 
most  exhaustive  study  of  wealth  distinction.  Dr.  Willford  I.  King 
estimated  that  in  1910,  95  per  cent,  of  the  families  of  the  continental 
United  States  had  incomes  of  less  than  |2,000  a  year;  that  82  per 
cent,  had  incomes  of  less  than  |1,200,  and  that  69  per  cent,  were 
living  on  less  than  |1,000.^ 

The  wages  found  in  the  study  of  infant  mortality  in  Johnstown, 
Pennsylvania,  showed  that  in  63.5  per  cent,  of  the  1,491  families,  the 
father  was  earning  less  than  f  1,200  a  year.  In  only  33  per  cent,  was 
the  income  designated  as  "ample".  This  study  included  rich  and 
poor  alike,  and  covered  the  homes  of  all  babies  born  in  1911  in  that 
city,  with  no  regard  for  district  or  circumstances. 

Wage  statistics  obtained  in  the  various  surveys  available  showed 
figures  at  wide  variance  with  the  common  statement  that  "all  wages 
have  increased  100  per  cent."^  In  January  and  February  1918  a 
study  was  made  of  four  representative  blocks  in  Manhattan,  and  wage 
figures  for  377  self-supporting  families  were  obtained.  The  incomes 
of  these  families  in  40  per  cent,  of  the  cases  had  increased  between 
January,  1917  and  January,  1918.  In  another  40  per  cent,  no  increase 
had  come,  and  in  20  per  cent,  an  actual  decrease  had  been  suffered. 

/,\^^'">!P'?,  '^^^*'"  ^^"F'   "Health  and  Income  of  the  People  of  the  United  States,"  pp.  214-230. 


92 

There  were  574  wage  earners  in  these  families;  the  wages  of  31  per 
cent,  had  increased ;  57  per  cent,  had  had  no  increase  and  12  per  cent, 
had  had  their  wages  decreased.  Yet  in  January,  1918  in  New  York 
the  cost  of  living  had  so  risen  that  a  dollar  had  only  four-fifths  the 
purchasing  power  which  it  had  in  January,  1917. 

In  the  Philadelphia  Survey  which  covered  1,850  families  in  seven 
districts  in  Philadelphia  the  average  family  income  was  but  |21.60 
a  week,  and  almost  a  third  of  these  families  contained  over  five 
persons — the  normal  standard. 

In  the  Visiting  Nurse  Study,  80.6  per  cent,  of  the  438  families  had 
incomes  of  less  than  |30.00  a  week.  In  the  Sickness  and  Dependency 
Study  94.3  per  cent,  of  the  families  had  incomes  of  less  than  this 
amount. 

Wages  for  women,  proverbially  lower  than  those  for  men,  proved 
in  the  Working  Womens'  Study  to  be  in  98.1  per  cent,  of  the  cases 
under  |25.00  a  week ;  in  92  per  cent,  of  the  cases,  under  |20.00. 

In  the  Pittsburgh  Factory  Investigation,  made  in  August-Novem- 
ber, 1918,  covering  the  work  places  of  over  9,000  women,  it  was  found 
that  in  70  per  cent,  of  the  operations  the  wages  were  between  |5.00 
and  |15.00  per  week.  In  only  two  processes  were  the  weekly  wages 
over  125.00. 

In  a  study  made  by  the  Consumers'  League  in  New  York  in  1916-17, 
among  417  women  working  in  steam  laundries,  it  was  found  that  78.'> 
I)€r  cent,  earned  less  than  flO.OO  a  week,  and  almost  half  earned  less 
than  18.00.  \ 

The  Kensington  Survey,  which  covered  the  most  representative  in- 
dustrial group,  showed  that  more  than  half — 56.5  per  cent,  of  the  608 
families — had  incomes  under  |30.00  a  week.  Forty-two  per  cent, 
were  living  on  less  than  |25.00  a  week. 

A  veiy  comprehensive  statement  of  recent  wage  changes  has  just 
been  published  by  Hugh  S.  Hanna  and  W.  Jett  Lauck.^  As  the 
result  of  an  intensive  study  of  the  records  and  publications  of  various 
state  and  national  departments,  and  several  first-hand  investigations, 
they  find  that  the  rise  in  wages  between  1914-15  and  December,  1917 
or  January  1918,  was  only  18  per  cent,  for  anthracite  miners,  26  per 
cent,  for  machinists  in  the  Philadelphia  Navy  Yard,  30  per  cent,  for 
bituminous  miners  working  by  hand,  and  34,  36  and  37  per  cent, 
respectively  for  shipsmiths,  shipfitters  and  pipefitters  in  the  Phila- 
delphia Navy  Yard.  The  rise  in  the  building  trades  was  but  12  to 
20  per  cent.  Some  industries  had  actual  decreases,  and  some  re- 
mained almost  stationary.  The  chief  industries  in  which  exceptional 
gains  occurred  during  this  same  period  were  bituminous  mining  by 
machine,  39  per  cent.,  various  occupations  in  the  iron  and  steel  in- 
dustry, 60  to  67  per  cent.,  and  certain  classes  of  labor  in  the  ship- 
yards on  the  Delaware  River,  65  to  105  per  cent.^ 

(1)  "Wages  and  the  War,"  published  January,    3918, 

(2)  "Wages  and  the  War,"  page  6. 


93 

In  commenting  on  "the  Effect  of  the  War  on  Wages"  they  state: 

"During  the  past  few  years,  and  more  particularly  during  the 
period  of  the  war,  there  has  been  an  increase  in  money  wages  in 
practically  all  branches  of  American  industry.  But  there  has  beem 
ijbsolutely  no  uniformity  in  the  rate  of  increase.  In  some  trades 
there  have  been  wage  advances  that  a  little  while  ago  would  have,- 
appeared  wildly  incredible.  In  others  the  advances  have  been  very- 
moderate — little,  if  any,  greater  than  had  occurred  during  a  periodi 
of  equal  length  in  the  preceding  years  of  peace. 

The  great  advances  have  taken  place  in  those  lines  of  industry  for 
the  products  of  which  the  war  has  created  a  special  demand.  *  ♦  *  ♦ 
In  some  industries,  such  as  printing,  the  war  made  no  special  de- 
mands; in  still  others  it  had  a  depressing  effect.  Many  individual 
workers  in  these  trades,  of  course,  profited  by  transferring  themselves, 
to  war  industries,  *  *  *  *  but  this  is  not  always  the  case."^ 

In  contrast  to  this  wage  situation,  we  find  a  steady  increase  in  the; 
prices  of  food,  fuel,  and  other  necessities  of  life.  According  to  the; 
United  States  Bureau  of  Labor  Statistics,  retail  food  prices  in  Phila- 
delphia were  68.09  per  cent,  higher  in  August,  1918  than  in  December,, 
1914.2 

The  greatest  increases  occurred  in  the  items  of  clothing  and  house 
furnishing.    These  items  increased  over  a  hundred  per  cent. 

Philadelphia  was  included  in  the  studies  of  the  increase  in  cost 
of  living  recently  completed  in  ship-building  centers  by  the  Bureau 
of  Labor  Statistics.  The  measurement  of  increase  is  based  on  a  study 
of  price  fluctuations  for  five  groups  of  expenditures — food,  rent,  fuel 
and  light,  clothing  and  sundries.  The  increased  cost  of  living  was 
found  by  combining  the  increased  cost  of  each  of  these  five  classes, 
after  this  cost  had  been  weighted  according  to  its  relative  importance 
in  the  budget. 

According  to  the  figures  for  Philadelphia  the  cost  of  living  for 
white  families  based  on  these  necessities,  had  risen  67.17  per  cent,  in 
August,  1918,  over  the  cost  in  December,  1914.^  In  New  York  this 
increase  was  62.07  per  cent.  The  increase  in  New  York  has  been 
computed  up  to  December  1918,  and  is  75  per  cent.  If  Philadelphia 
costs  increased  in  like  manner,  the  cost  of  living  was  in  December, 
1918,  80.10  per  cent,  higher  than  in  December  1914.  The  cost  of 
living  in  Philadelphia  was  found  by  the  investigators  to  be  higher 
than  in  New  York,  Boston  or  Chicago. 

Wholesale  figures  tell  a  more  startling  story.  From  July  1,  1914, 
to  April  1,  1918,  the  wholesale  prices  of  forty-six  commodities  given 
in  Bradstreet's  Trade  Journal  showed  a  rise  of  115  per  cent. 

The  standard  "Minimum  of  subsistence"  budgets  made  in  New 
York  of  |845,^^  |876*  and  ^900^  for  a  family  of  five,  became  in  June, 
1918,  |1,320,  |1  360,  and  |1,390  respectively.  v 

(')  "Wages   and   the  War,"   page   3. 
(2) Monthly  Review  October,   1918,   page  119. 

(») Estimate  of  Bureau  of  Personal  Sei-vine  of  the  Board  of  Estimate  and  Apportionment  of 
New  York   Cltv,   for  unslcilled  laborer's  family,    1915. 

(*) Estimate  of  New  York  Factory  Investigating  Coiwntssion,   1914. 
(«)Estimatc  of  Dr.  Chapin,  1907. 


The  Philadelphia  Bureau  of  Municipal  Research  stated  in  Decem- 
ber 1917,  that  the  necessary  minimum  cost  of  healthful  living  for  a 
family  of  two  adults  and  three  children  was  |1,200  a  year.  In  the 
cost  of  living  study  which  this  Bure^lu  is  now  completing,  the  mini- 
mum budget  will  b^  between  .^1^625  and  |1,650.* 

The  United  States  Bureau  of  Labor  Statistics  estimates  that  iti 
November^  1918,  the  winiinum  necessary  for  Subsistance  for  an  aver- 
age family  in  a  large  eastern  City  is  about  |1500  and  the  National 
War  Labor  Board  drew  up  a  "minimum  comfort^'  budget  in  June, 
1918,  which  amounted  to  |l,tf>0  per  year  fof  a  family  of  five.^ 

In  spite  of  rumors  of  Universally  inci*eased  wages,  in  Kew  York 
City,  the  percentage  of  undernourished  school  children  had  more  than 
doubled  in  1916-1?  as  compared  with  1914.  Five  per  cent,  of  the 
children  istudied  in  1914  were  "seriously"  undernourished.  In 
191647, 12  per  cent,  were  so  affected.^ 

A  few  employers  have  made  provision  for  periodic  increases  in 
wages,  in  accordance  with  the  increase  in  the  cost  of  living.  For 
tM  most  part,  however,  the  wage  increases  have  been  wholly  un- 
standardi»cd,  except  when  fixed  by  the  government.  On  July  12, 
191S>  the  National  War  Labor  Board  fixed  a  minimum  of  40  cents 
;aa  hour  for  unskilled  laborers  in  a  machine  shop  at  Waynesboro, 
Pa.,  stating  that  this  was  the  smallest  sum  for  which  a  laborer  could 
support  a  family. 

On  the  2ord  of  November,  1918,  in  Kensington,  2,000  carpet  weavers^ 
went  out  on  strike,  claiming  that  they  could  not  live  on  their  pay,  \ 
which  aVi^l-Uged  |25.00  a  week,  and  asking  for  an  increase  of  |15.00. 

\t  is  Signficant  that  in  76.5  per  cent,  of  1,156  strikes,  occurring  dur- 
ing the  first  six  months  of  the  war,  and  studied  by  the  National  In- 
tlustrial  Conference  Board,  the  demand  was  for  increased  wages,  and 
38.5  per  cent,  of  these  strikes  were  called  for  this  reason  alone.  The 
Conference  Board  states  first,  among  the  causes  responsible  for  these 
strikes,  the  "increased  cost  of  living  and  failure  of  employers  in 
many  cases  to  anticipate  this  influence."  The  second  cause  of 
primary  importance  is  the  "widespread  discontent  due  to  a  belief 
that  undue  profits  had  been  made  by  employers  out  of  war  business," 
and  the  third  is  the  "inequality  between  wages  paid  in  plants  engaged 
on  private  work  and  government  or  private  plants  engaged  on  war 
work."* 

It  is  evident  that  the  wages  of  Pennsylvania  employees  during 
the  past  four  years  have  shown  uneven  fluctuations,  varying  from 
increases  of  105  per  cent,  in  certain  war  industries  to  less  than  20 
per  cent,  in  a  considerable  number  of  others,  to  actual  decreases  in 

(1)  Authorized  statement  of  William  C.  Beyer,  Assistant  Director  of  Philadelphia  Bureau  of 
Mimicipal  Research. 

(2)0gbum,  Wm.  F.,  "Measurement  of  Cost  of  Living  and  Wages,"  Annals  of  American  Academy 
of  Political   and  Social   Science.    January,    1919. 

(«) Baker,   S.   J.,    "War  and  Nourishment  of  Children."  1918,   pa»f»  7. 

(*) "Strikes  in  American  Industry  jji  War  Times,"  National  Industrial  Conferpiiee  Board,  March, 
1918,  pp  9  and  20.  


a  few  cases.  Meanwhile  the  cost  of  the  necessary  articles  which  poor 
as  well  as  rich  mnst  buy  has  steadily  increased  until  today,  at  the 
very  least  it  is  75  per  cent,  higher  than  it  was  in  December,  1914. 
The  effect  of  such  conditions  on  the  ability  of  wage-earners  to  ac- 
cumulate savings  with  which  to  meet  periods  of  sickness  needs  no 
explanation.  And  yet,  as  every  survey  has  shown,  sickness  with  its 
accompanying  losses  is  a  risk  certain  in  too  many  instances  to  bank- 
rupt the  family  that  has  made  no  adequate  provision  for  it. 

Loss  of  Wot^king  Time  on  Account  of  Sickness. 

An  average  of  six  days  lost  from  work  by  each  employee  each  year 
on  account  of  sickness,  which  was  the  low  figure  reached  in  the  first 
section  on  the  extent  of  sickness,  may  not  seem  a  particularly  long 
period.  It  looms  larger,  perhaps,  wlien  it  is  realized  that  the 
2,800,0()0  wage-earners'  in  the  state  are  losing  16,800,000  days  a 
year  through  sickness.  The  coal  miners  are  losing  2,142,000  days,  in 
which  time  four  and  one-half  million  tons  of  coal  could  be  extracted. 

In  the  study  of  the  families  coming  to  the  Visiting  Nurse  Society, 
13,528  working  days  were  lost  during  the  year  by  201  wage-earners. 
This  means  an  average  of  sixty-seven  days  for  each  of  them,  or  nine- 
teen days  for  each  wage-earner  in  the  study,  sick  or  well.  Of  this  lost 
time,  alpaost  one  third  was  lost  by  only  nine  men.  Only  40  per  cent, 
of  the  201  wage-earners  lost  less  than  two  weeks,  and  46  per  cent,  of 
them  lost  from  one  to  six  months  each. 

In  the  Kensington  Survey,  421  cases  of  illness  of  wage-earners  were 
noted.  The  average  length  per  case  was  thirty-eight  days,  or  over 
five  weeks.  This  comparatively  short  average  period,  together  with 
the  heavy  burden  of  the  actual  illness  would  seem  to  indicate  strongly 
that  some  method  of  equalizing  and  distributing  the  loss  from  illness 
would  be  desirable.  Under  present  conditions,  employees  are  either 
unable  or  unwilling  to  take  time  off  for  minor  disabilities,  so  that 
illness  when  it  does  occur,  is  more  serious  and  prolonged. 

Loss  of  Money  on  Account  of  Sickness. 

The  figures  on  the  duration  of  illnesses  among  employees  give  some 
indication  of  the  wage-loss.  A  total  loss  of  wages  almost  always 
occurs  during  absence  from  work  because  of  illness.  Only  the  skilled 
workers  and  salaried  employees  are  more  fortunate;  in  fact,  the 
average  wage-earners  may  consider  themselves  fortunate  if  their 
places  are  saved  for  them  until  their  return.  In  the  study  of  Work- 
ing Women,  the  wage  was  continued  in  only  three  instances,  while  in 
the  647  cases  of  the  illness  of  a  wage-earner  among  the  families 
in  the  Sickness  and  Dependency  Study,  the  wage  was  continued  in 

(1)1918  eV^timate. 

7 


9G 

just  one  instance.  In  one  other  case  a  part  of  the  wage  was  paid, 
and  in  thirty-three  cases  the  employer  gave  some  help  as  a  matter  of 
charity. 

We  may  roughly  reckon  the  total  wage-loss,  therefore  for  Pennsyl- 
vania employees  for  a  year,  as  the  average  wage  multiplied  by  the 
number  of  days  lost.  At  1916  rates  this  would  average  a  little  more 
than  114.00  per  employee  per  year,  or  a  total  of  |39,200,000  for  the 
2,800,000  employees  in  the  state. 

In  the  Kensington  Survey^  the  wage  loss  was  reported  in  367  cases 
of  the  illness  of  wage-earners..  The  average  per  case  was  |78.53, 
01  more  than  a  month's  pay  of  a  single  wage-earner  according  to  the 
family  incomes  found  in  the  survey. 

This  is  an  average,  giving  no  picture  of  the  actual  suffering  of 
those  who  are  sick  for  long  periods.    It  tells  little  of  the  problem  of 
Mr.  R,  a  laborer  earning  |13.00  a  week  and  supporting  a  wife  and! 
three  little  girls,  eleven,  nine  and  six,  and  a  baby  boy  a  jesar  old.- 
For  more  than  two  years,  although  suffering  with  tuberculosis',-  he- 
kept  on  at  work.     But  when  his  strength  finally  failed  and  he  was- 
sent  to  a  state  sanitorium,  his  family  had  no  means  of  support,  an^ 
although  he  was  supposed  to  have  contracted  the  disease  in  the  course 
of  his  work,  his  employer  gave  but  |10.00.     For  eight  months  the 
church  and  a  relief  society  cared  for  the  family,  the  latter  contribut- 
ing several  hundred  dollars.  '  \ 

It  is  easy  to  see  that  the  average  employee^  unless  he  has  other 
wage-earners  in  the  family  or  relatives  able  to  help  him,  may  find  the 
wage-loss  from  illness  alone  an  iniotefahte  burden,  eating  up  his 
savings,  piling  up  debts  and  loivering  Ms  Whole  standard  of  living. 

Cost  of  Medical  Care. 

Over  and  above  the  loss  in  wages  must  be  reckoned  the  cost  of 
medical  care  for  employees  and  their  families.  Certain  fee-schedules? 
of  the  medical,  dental  and  nursing  professions  and  of  hospitals  are; 
presented.  Considering  the  professional  skill  and  the  responsibility- 
involved,  nlany  of  the  fees  are  most  moderate.  They  are  given  to) 
show  what  employees  in  this  state  must  pay,  under  present  condi- 
tions, to  receive  medical  care  on  an  independent,  full-cost  basis.. 
They  cannot  be  taken  to  represent  the  actual  charges  made  but  repre-^ 
sent  merely  the  standard  minimum  fee  for  regular  professional  serv- 
ices, exclusive  of  attention  from  specialists. 

Physicians'  fee  schedules,  as  published  by  various  county  medical 
societies,  range  from  fifty  cents  to  |5.00  for  an  office  visit,  and  from 
11.00  to  13.00  for  a  house  call.  Special  rates  are  made  for  operations, 
pnd  the  lowest  price  for  obstetrical  services  is  flO.OO.  Many  of  these 
schedules  are  being  revised  and  prices  raised.     In  three  counties 


97 

a  40  to  50  per  cent,  increase  has  been  announced.  Rates  are  lower 
in  the  rural  districts  than  in  the  cities.  Dental  rates  throughout 
the  state  range  from  |3.00  to  |5.00  an  hour.  When  charges  are  de- 
termined by  the  nature  of  the  work  done,  rather  than  by  the  time 
consumed,  amalgam  or  cement  fillings  and  treatments  cost  from  fl.OO 
up;  gold  fillings,  from  |2.00;  and  bridge  work,  |8.00  to  |12.00  per 
tooth-  Trained  nurses'  fees  are  from  .f^25.00  to  .f35.00  a  week  for 
ordinary  cases,  frequently  with  extra  charges  for  nervous  and  ob- 
stetrical cases.  Ward  beds  in  hospitals  cost  from  flO.OO  to  |14.00 
a  week,  and  a  charge  of  |5.00  to  $10.00  for  the  use  of  the  operating 
room  is  customary.^ 

Naturally,  many  employees  cannot  pay  these  charge?.  As  a  result, 
we  have  physicians  and  hospitals  giving  service  free,  or  at  reduced 
rates,  a  host  of  medical  or  semi-medical  charities,  and  throngs  at 
the  free  dispensaries,  as  well  as  numerous  cases  of  entire  failure  to 
receive  medical  care  where  it  is  sadly  needed.  Charity  practice  im- 
poses an  unjust  burden  upon  the  medical  profession  and  undermines 
the  self  respect  of  the  recipients  to  an  extent  which  seems  wholly 
inconsistent  in  a  democracy. 

What  wage-earners  and  their  families  actually  pay  out  for  medical 
care  in  time  of  sickness,  has  been  ascertained  from  the  available  sur- 
vey material. 

Here  again  "average  expenditures"  give  no  idea  of  the  real  burden 
imposed.  In  the  Visiting  Nurse  Society  Study  for  instance,  more 
than  half  the  expenditure  for  sickness  was  borne  by  less  than  one- 
seventh  the  number  of  families.  While  29  per  cent,  of  the  families 
escaped  with  health  expenditures  of  less  than  $10.00,  fifty  families 
spent  over  flOO.OO ;  ten  spent  over  |300.00,  and  thirteen  families  had 
medical  and  dental  expenditures  amounting  to  more  than  20  per 
cent,  of  their  total  incomes.  In  the  study  of  Working  Womens' 
Records,  one-fourth  of  the  total  expenditure  was  made  by  only  ten 
girls;  the  intolerable  burden  of  the  self-supporting  working  woman 
confronted  with  a  bill  of  |685.00  for  two  operations  needs  no  ampli- 
fication. 

Approximately  one-third  of  the  families  studied  in  the  various 
surveys  had  annual  expenditures  of  more  than  |50.00.  The  largest 
single  group  spent  between  $20M  and  ,%30.00.2 

Invariably  the  largest  item  of  health  expenditure  was  the  cost  of 
a  physician's  care.  The  following  table  classifying  each  detail,  gives 
a  fair  idea  of  the  proportion  spent  on  different  items  by  low-income 
families.  The  group  of  260  families  covered  in  the  study  were  "self- 
supporting,"  but  in  no  case  was  the  principal  wage-earner  receiving 
an  income  of  over  |2,000: 

(i)See   tahles  VI  A,   B.   C,    and  D   at  the  end   of  this   section. 

(2) Table  VII  at  end  of  sertion  ^ves  the  exact  distribution  of  medical  and  dental  expenditures. 


98 


AVERAGE  ANNUAL  HEALTH  EXPENDITURES  FOR  VARIOUS  OBJECTS.i 


Families 

All 

Reporting 

Families 

Expenditures. 

(200). 

a> 

<u 

Objects  of  Expenditure. 

S 

0 

3 

5 

i 

•o 

•o 

s . 

«i-i 

a>> 

p.t>> 

«t-i 

kS 

o 

o.g 

«g 

W  03 

a>  93 

-    M 

tXHi 

ftfi'w 

a 

3 

»-i  fe 

^^  fe 

g^P. 

^s. 

Iz; 

<i5 

<1 

All  objects,   

Physicians,   

Dentist,  

Oculist,   — 

Nurse, 

Surgical  appliances,    

Medicine  prescribed  by  physician 

Other  medicines,   

Hospital  charges,   

Dispensary  charges,  

Spectacles  (and  eye-glasses),  — 
Unspecified,    


258 

$32  55 

217 

20  63 

97 

13  02 

20 

936 

22 

17  73 

9 

983 

79 

5  11 

184 

5  05 

20 

12  54 

10 

5  68 

52 

583 

1 

100  00 

$32  30 


17  14 
4  86 

72 
1  50 

23 
1  55 
3  57 

96 

1  17 


This  average  expenditure  of  |32.30  per  family,  raised  to  1918  fig- 
ures, would  become  |37.00,  if  we  may  assume  that  health  expenditures 
have  risen  in  cost  at  the  same  rate  as  general  household  expenditures.^ 
This  is  somewhat  lower  than  average  expenditures  obtained  in  1918 
surveys.  Among  the  Visiting  Nurse  Society  families  the  average  of 
the  363  reporting  expenditures  was  over  |47.00.  For  the  Working 
Women  the  average  for  the  284  girls  where  expenditures  were  known 
was  127.78. 

Special  figures  for  the  health  expenditures  of  the  Philadelphia  and 
Chester  families  covered  by  the  Cost  of  Living  Study  of  the  United 
States  Bureau  of  Labor  Statistics  were  segregated  for  the  Commis- 
sion. In  Philadelphia  188  families  out  of  192  reported  health  ex- 
penditures— the  average  being  |43.29.  In  Chester  forty  families 
reported  an  average  of  |48.93.  The  average  cost  of  medical  care 
alone  was  |36.23  in  Philadelphia  and  |37.90  in  Chester.  Dental  ex- 
penditures were  much  smaller — 113.83  and  |16.98  respectively.  In 
another  study  of  the  Cost  of  Living  made  by  the  Bureau  of  Labor 
Statistics  the  average  annual  health  expenditure  for  292  white  fami- 
lies was  143.59 ;  for  230  negro  families  the  average  was  |20.19. 

One  of  the  most  interesting  items  of  expenditure  is  that  for  patent 
medicine.  The  large  amount  of  patent  medicine  consumed  by  wage- 
earners  and  their  families  was  one  of  the  chief  points  which  im- 
pressed the  nurses  who  made  the  Visiting  Nurse  Society  Study  for 
the  Commission.    Many  families  attempted  to  ward  off  the  need  and 


(MThe  cost-of-living  Study  made  by  Philadelphia  Bureau  of  MTinicipal  Research,  1917. 
(2) Authorized  statement  of  Wm.  C.   Beyer,  Director  of  the  Study. 


99 

the  expense  of  a  physician  by  investing  in  patent  medicines.  In  the 
Cost  of  Living  Study  of  the  Philadelphia  Bureau  of  Municipal  Re- 
search, 184  families  out  of  258  reported  expenditures  for  medicine 
other  than  that  presmhed  hy  a  physician.  The  average  expenditure 
was  over  |5.00,  and  for  all  the  families  covered  this  average  was 
|3.57,  as  against  an  average  of  fl.55  for  the  medicine  tvhich  ivas 
prescribed.  During  the  year,  ten  families  had  spent  over  |20.00  oa 
these  patent  medicines.  Two  families  in  the  Sickness  and  Depend- 
ency Study  reported  that  often  |6.00  or  f8.00  a  month  went  for 
medicines,  in  the  hope  that  cure  would  come  and  prevent  further 
expense  or  an  "out-of-work"  period. 

Especially  interesting  in  this  connection  were  the  results  of  the 
surveys  of  the  Old  Age  Pensions  Commission  made  in  industrial 
districts  of  Pittsburgh,  Reading  and  Philadelphia.  Facts  for  men 
and  women  over  fifty  years  of  age  were  tabulated,  and  special  items 
Avere  secured  for  the  Health  Insurance  Commission  on  expenditures 
for  medicine.  In  three  cities 'figures  on  expenditures  for  "medicine 
only"  were  secured  for  1,209  people.  Three-fifths  of  these  individuals 
had  monthly  expenditures  for  medicine.  In  10.2  per  cent,  of  the 
cases  this  monthly  expenditure  amounted  to  over  |4.00,  and  in  3.6 
per  cent.,  to  over  flO.OO. 

In  Pittsburgh  16.5  per  cent,  of  the  207  individuals  for  whom  this 
information  was  secured,  spent  regularly  an  average  of  over  |4.00 
a  month  for  "medicine  only."  In  Reading,  where  information  for 
721  individuals  was  secured,  the  percentage  s^pending  over  four  dol- 
lars a  month  was  3.6;  in  Philadielphia  it  was  4.1  per  cent.  The  in- 
jurious effect  of  the  constant  and  haphazard  use  of  medicines  with- 
out medical  advice  is  well  known. 

The  average  expenditures  for  health  purposes  in  wage-earners' 
families  seem  to  bear  a  direct  relation  to  the  amount  of  income.  In  a 
study  in  1917  by  the  United  States  Bureau  of  Labor  Statistics  health 
expenditures  for  a  group  of  families  in  Washington  were  tabulated. 
The  average  expenditure  increased  as  the  income  increased: 


Number  of  Families. 

• 
Average  Annual  Income. 

Average  Expenditure 
for  Medical  Care. 

46 
117 
187 
196   . 
191 

Less  than  $600  00 

$600  00—    900  00 

900  00—1,200  00 

1,200  00—1,500  00 

1,500  00  and  over 

$12  83 
25  52 

42  31 

43  16 
59  57 

The  cost  of  medical  care  comes  many  times  as  an  emergency  and 
places  upon  the  individual  a  hurden  out  of  all  proportion  to  his  re- 
sponsibility.   The  problem  is  one  of  a  just  method  of  distribution. 


100 

Loss  of  Future  Earning  Power. 

The  possible  loss  of  future  earning  power  is  the  most  important 
risk  of  the  wage-earner.  Unless  he  is  rehabilitated,  he  himself,  his 
family,  and  society  all  suffer  irretrievably.  The  temporary  loss  of 
wages  and  the  cost  of  medical  care  are  indeed  minor  matters  com- 
pared with  the  prospect  of  facing  the  future  obliged  to  support  him- 
self and  his  dependents  on  rejiuced  earning  power,  or  unable  to 
support  them  at  all. 

Any  attempt  to  aid  in  the  solution  of  the  sickness  problem  must 
have  as  its  goal  the  complete  restoration  of  the  sick  man  or  woman 
to  health.  To  this  end^  imimcdiate  and  adequate  medical,  surgical  and 
institutional  care  must  he  made  available,  and  the  contingency  of 
Suspension  of  earnings  during  the  periods  necessary  for  recovery 
must  be  met.  This  is  but  justice  to  the  disabled  person,  to  industry 
and  to  the  community  at  large. 

LOSSES  TO  INDUSTRY  BECAUSE  OF  SICKNESS  OF 
EMPLOYEES. 

Industry  has  not  generally  counted  among  its  costs  of  operation, 
the  losses  which  it  suffers  because  sickness  daily  keeps  thousands  of 
employees  from  work,  sends  others  to  their  places  in  a  partially 
disabled  condition,  and  every  year  permanently  unfits  hundreds  of 
men  and  women  for  productive  effort.  Because  of  the  lack  of  accurate 
records,  it  is  impossible  to  exactly  measure  the  extent  of  this  enor- 
mous industrial  loss,  but  from  our  knowledge  of  the  extent  and 
seriousness  of  disease  among  wage  earners,  and  from  the  testimony 
of  those  few  employers  who  have  come  to  realize  that  the  good  health 
of  their  work  people  is  an  essential  to  business  success,  we  can  draw 
some  conclusions. 

The  fact  that  every  year  Pennsylvania's  working  men  and  women 
lose  over  sixteen  million  working  days  because  of  illness  gives  some 
indication  of  the  coal  that  is  not  loaded,  the  rivets  that  are  not  driven, 
the  seams  that  are  not  welded  because  the  workers  are  away,  sick. 
The  coal  mines  alone  lost  at  this  rate  2,142,000  working  days — time 
enough  to  mine  four  and  one-half  million  tons  of  coal,  sufficient  to 
supply  the  city  of  Philadelphia  for  a  year  and  a  half.  And  to  that 
must  be  added  the  wastage  and  inefficient  work  of  that  large  number 
of  employees  who,  although  really  sick,  "cannot  afford  to  lose  the 
time."  The  work  done  by  such  half  sick  or,  as  often  happens,  by 
seriously  sick  men,  is  almost  certain  to  be  inferior  in  quality  and 
the  danger  of  industrial  accidents  is  greatly  increased  by  their  pres- 
ence. In  the  majority  of  such  cases,  no  medical  care  is  secured, 
powers  of  resistance  are  weakened,  and  susceptibility  to  disease  is 
increased.  Often  chronic  disease  develops  from  an  illness  which 
would  have  amounted  to  little  if  treated  in  its  incipient  stages. 


101     , 

The  recent  influenza  epidemic  reduced  the  anthracite  coal  output 
of  the  state  500,000  tons  in  the  course  of  a  few  weeks.  "It  went 
raging  through  the  mines,  striking  down  thousands  of  men,  killing 
some,  leaving  others  so  weak  that  they  will  not  be  themselves  for 
months."^  Because  it  was  spectacular,  this  loss  was  widely  appre- 
ciated and  commented  upon — but  no  attention  is  paid  to  the  steady^ 
never-ceasing  inroads  made  on  production  of  a'l  kinds  b}^  the  non-epi- 
(demic  sickness.  We  are  so  accustomed  to  it  that  we  do  not  realize 
iWhat  could  be  accomplished  without  the  hampering  influence  of  that 
ifull  half  of  it  which  could  be  entirely  prevented. 

jIn  co-operation  with  the  Ohio  Health  and  Old  Age  Insurance  Com- 
imission,  the  record  *ards  of  115,648  members  of  the  Voluntary  Relief 
Department  of  the  Pennsylvania  Railroad  (East)  were  examined  by 
tthe  Commission,  and  all  illnesses  and  industrial  accidents  for  which 
Ibenefits  had  been  paid  to  these  members  during  the  five  years  1913- 
1917  were  tabulated.  As  it  was  impossible  to  tell  which  men  had  been 
members  of  the  Department  during  the  entire  period,  no  sickness 
i^ate  could  be  obtained  from  the  study,  but  the  duration  of  each  of 
ttlie  27,055  cases  of  industrial  accidents  and  64,849  cases  of  sickness 
was  recorded.  For  1917  the  cards  examined  showed  5*,103  industrial 
accidents  and  13,023  cases  of  sickness,  each  of  which  was  of  less  than 
100  days'  duration-  The  total  numlier  of  icorJcmg  days  lost  through 
the  accidents  teas  60,215^  while  the  sickness  cases  caused  a  loss  of 
165,002  working  dayn.  In  addition,  there  were  tabulated  111  indu.^- 
trial  accidents  and  236  cases  of  sickness,  each  of  which  lasted  longer 
than  100  days.  When  we  see  that  the  total  number  of  sickness  cases 
tabulated  in  the  annual  report  of  the  Relief  Fund  for  1917  is  62,744, 
cr  more  than  four  and  one-half  times  the  number  w^hich  the  Com- 
mission studied  for  that  year  we  realize  the  tremendous  loss  to  this 
one  company  alone  through  sickness  among  its  employees. 

The  AVestinghouse  Electric  and  Manufacturing  Company  of  Pitts- 
( burgh  also  has  a  relief  department,  whose  records  show  that  for  the 
month  of  August,  1915,  members  of  the  departmejit  lost  6,654  days 
;-because  of  sickness.  This  was  not  an  abnormal  month,  Jjut  record^ 
:ior  other  months  were  not  available. 

Specifically,  sickness  has  a  close  relation  to  several  factors  whose 
(bearing  on  production  and  prosperity  is  important.  Not  only  the 
(Casual  laborer,  but  the  skilled  mechanic,  engineer  or  miner  is  at- 
itaeked  by  disease.  The  absence  of  such  an  employee,  or  the  attempt 
to  replace  him  with  a  new  or  inexperienced  worker,  causes  serious 
loss  through  reduction  in  output,  spoilage  of  material  and  incomplete 
use  of  machinery,  lighting  and  heating  equipment.  In  many  indus- 
tries it  costs  from  |30.00  to  |50.00  to  hire  and  initiate  a  new  em- 


(1) Francis  A.  Lewis,  Federal  Fuel  Administrator  for  Philadelphia,  November  24,  1918, 


ttt: 


: ;  ;>.  ':■:.■  ■  ^  .••102 

ployee,  and  in  the  case  of  a  skilled  mechanic  the  cost  may  be  as  high 
us  POO^OOO.  In  both  the  Kensington  and  the  Visiting  Nurse  Studies, 
covering  largely  skilled  and  semi-skilled  industrial  workers,  the 
average  time  lost  by  disabled  employees  was  thirty-eight  and 
sixty-nine  days>espectively ;  approximately  half  the  illnesses  in  every 
group  studied  lasted  longer  than  one  month.  In  many  such  cases, 
the  employer  is  forced  to  fill  the  place  of  the  absent  worker,  and 
"labor  turnover,"  one  of  the  most  costly  factors  in  industry,  is  in- 
creased. Thomas  I.  Read,  of  the  New  Jersey  Zinc  Company's  Tech- 
nical Department,  after  a  careful  study  of  working-time  lost  on  ac- 
count of  both  sickness  and  accident  states  that,  "As  in  the  case  of 
accidents,  when  the  man  is  absent  another  mafti  must  be  supplied  to 
take  his  place,  and  this  increases  both  the  labor  turnover  and  the 
accident  rate;  in  other  words  it  is  a  source  of  considerable  loss  to 
the  company  as  Avell  as  to  the  man."^  Time  lost  by  employees  of  this 
company  through  illness  amounts  to  four  times  the  loss  from  acci- 
dents. 

Realization  of  the  seriousness  of  the  situation  is  compelling  some 
employers  largely  as  a  business  proposition  to  institute  more  or  less 
complete  medical  care  for  sick  employees,  and  to  encourage  the  for- 
mation of  establishment  funds  for  the  payment  of  cash  sick  benefits. 
The  Bell  Telephone  System  maintains  entirely  at  its  own  expense 
i)  system  of  sickness  insurance  providing  for  the  payment  of  sick 
benefits  to  sick  employees.  The  rate  and  the  duration  of  payment 
are  based  on  the  wage  rate  and  the  length  of  service,  and  substantial 
death  benefits  and  pensions  are  paid.  Mr.  Charles  G.  DuBois,  Comp- 
troller of  the  Bell  System,  says,  "This  plan  is  not  in  any  sense  a 
charity,  and  it  is  not  so  regarded  by  employees.  It  is  an  attempt  to 
deal  justly  and  practically  with  one  of  the  problems  arising  under 
modern  industrial  conditions.  As  we  see  it,  the  men  and  women 
who  give  their  working  lives  to  furnishing  telephone  service  are 
fairly  entitled,  as  a  part  of  their  condition  of  employment,  to  know 
that  they  will  not  face  destitution  in  sickness  or  in  old  age,  and 
that  if  they  die  in  the  service  their  dependents  will  receive  some 
financial  provision  for  their  immediate  needs.  If  this  is  a  fair  and 
reasonable  condition  of  employment,  then  its  cost  is  rightfully  a  part 
of  the  cost  of  giving  telephone  service  and  we  so  regard  it.  *  *  * 
Just  as  the  cost  of  accidents  puts  on  the  employer  and  manager  an 
economic  incentive  to  develop  safety  appliances,  so  the  cost  of  sickness 
insurance  directly  stimulates  an  interest  in  the  prevention  of  sickness 
*  *  *  We  feel  that  we  are  started  on  the  right  road,  that  the 
problems  involved  are  not  essentially  different  from  other  business 
problems  which  have  to  be  worked  out  carefully  and  thoughtfully, 
that  the  advantages  of  sickness  insurance  from  a  business  point  of 


(*)Report  of  New  Jersey  Health  Insurance  Commission,  page  17. 


103 

vieio  are  prohahly  worth  the  cost,  and  tliat  whatever  the  cost,  the 
responsibility  for  healthful  working  conditions  and  the  duty  of  pro- 
viding financial  aid  for  the  workers  when  they  are  incapacitated  rest 
squarely  on  the  industry."^ 

Satisfaction  with  the  results  of  attempts  to  reduce  sickness  losses 
seems  to  be  general  among  employers  who  have  tried  them.  A  large 
Massachusetts  company  which  has  established  a  system  of  complete 
medical  treatment,  including  hospital  care,  for  its  employees,  finds 
that  "the  hours  per  year  lost  by  employees  who  take  advantage  of  its 
hospital  facilities  amount  to  only  half  as  many  as  are  lost  by  those 
who  do  not  accept  this  care."^  "It  is  to  the  direct  interest  of  the  com- 
pany as  Avell  as  the  individual,"  declares  a  member  of  the  famous 
silk  firm  of  Cheney  Brothers,  "to  bring  about  a  re-establishment  of 
health  and  consequently  efficiency,  by  supplying  the  best  conditions 
possible  for  recovery."^  "The  modern  employer,"  according  to  the 
medical  director  of  the  Cincinnati  Milling  Machine  Co.,  "has  learned 
that  the  health  of  the  worker  is  a  definite  asset  in  his  business.  Med- 
ical care  in  industry  is  not  charity.    It  pays  good  dividends. "^ 

Unfortunately,  the  employers  who  are  taking  effective  steps  to  re- 
duce this  industrial  loss  are  few  in  number,  and  the  attempts  are 
confined  as  a  rule  to  the  large  and  more  progressive  establishments. 
Moreover,  scarcely  any  provision  is  being  made  for  sickness  among 
members  of  employees'  families,  which,  next  to  the  illness  of  the 
workers  themselves,  most  reduces  their  efficiency.  In  the  few  cases 
where  industrial  nui  ses  are  being  employed  to  visit  the  homes  of  em- 
ployees and  give  needed  care  and  public  health  instruction,  marked 
improvements  not  only  in  general  habits  of  living,  but,  in  the  health 
of  the  workers,  are  noted. 

The  war,  with  its  em})hasis  on  production,  has  created  a  growing 
recognition  of  the  need  for  a  means  of  reducing  sickness-losses  which 
may  be  shared  alike  by  large  and  small  industrial  concerns.  The 
f(;llowing  extract  from  the  January,  1919,  issue  of  "The  Nation's 
Business,"  published  by  the  United  States  Chamber  of  Commerce, 
presents  the  matter  from  t]j«  point  of  view  of  industry.  "If  the  casu- 
alty list  from  industry  could  be  printed  every  day  in  our  newspapers 
the  people  of  this  country  would  be  appalled  at  its  size.  In  one  year 
from  accidents  alone  it  is  over  eight  times  as  large  as  the  entire 
caf^'nnlties  among  our  troops  in  the  battlefields  of  Europe. 

"We  have  no  records  to  show  the  number  who  are  killed  or  dis- 
abled as  a  result  of  occupational  diseases  and  diseases  partially 
traceable  to  working  conditions,  but  these  undoubtedly  are  even  more 
shocking.  Each  year  adds  a  quarter  of  a  million  men  to  the  total 
number  of  incompetents  who,  on  account  of  disease  or  accident  are 
permanently  thrown  on  the  scrap  heap  because  their  handicaps  pre- 
vent them  from  continuing  at  their  old  occupation. 

(MCJiarlos  R.   DuBois,   in  an  address  before  The  National   Civic  Federation,   January  22    1917 
f2)Third  Report,  Committee  on  HealtJ^.   New  York  State  Federation  of  Labor,   1918,  page  8. 


10-i 

"This  casting  of  valuable  workers  needlessl}^  on  the  scrap  heap  must 
cease.  Industry  must  blaze  the  trail  in  this  conservation  and  re- 
clamation of  human  life.  The  prevention  of  accidents,  industrial 
hygiene  and  sanitation,  adequate  medical  and  surgical  care  for  the 
sick  or  injured  employees,  adequate  compensation  during  periods  of 
disability,  and  better  living  and  working  conditions  for  all  employees, 
are  the  proven  methods  which  will  stop  this  human  wastage."^ 

LOSSES  TO  THE  STATE  BECAUSE  OF  SICKNESS  OF 
EMPLOYEES. 

"In  the  health  of  the  people  lies  the  wealth  of  the  nation." 

Gladstone. 

The  direct  financial  loss  to  the  state  because  of  sickness  repre- 
sents for  the  most  part  public  effort  to  reduce  the  social  loss. 

It  would  be  impossible  .to  estimate  the  social  cost  of  sickness 
among  wage  earners  in  Pennsylvania.  Serious  reductions  in  effi- 
ciency and  productive  power,  lowered  morale  and  broken  standards 
of  living  and  of  home-keeping,  encouragement  given  to  the  growth 
of  invalidism,  economic  dependency,  and  physical  and  moral  degener- 
ation— these  evils,  which  can  but  result  from  the  uneven  and  often 
losing  fight  that  present  conditions  force  upon  the  sick  wage  earner, 
are  clearly  apparent;  but  because  the  toll  which  they  annually  col- 
lect is  too  vital  to  be  calculated  in  dollars  alone,  it  cannot  be  ac- 
curately measured. 

In  its  effects  upon  the  individual  worker  and  his  family,  and 
through  them  upon  the  present  and  potential  stamina  of  the  nation^ 
this  social  cost  of  sickness  is  far  more  important  than  the  financial 
cost.  T7?,e  health  and  strength  of  our  people  are  the  real  sources  of 
~our  wealth,  and  our  contemplation  of  money  spent  for  sickness  relief 
and  prevention  must  he  directed,  not  so  much  to  the  amount  of 
expenditure,  as  to  the  results  achieved  therehy.  "If,  as  alleged  by 
way  of  criticism,  the  health  service  is  costly,  it  can  be  proved  to  be 
the  best  possible  investment  to  meet  the  cost."^ 

Cost  of  Sickness  to  Public  Funds. 
Although  no  effort  has  been  made  by'^he  state  of  Pennsylvania 
to  equitably  distribute  the  cost  of  sickness,  state  appropriations  for 
the  work  of  the  State  Department  of  Health,  for  medical  charity  and 
for  relief  to  persons  incapacitated  on  account  of  sickness,  amount 
eacli  year  to  millions  of  dollars.  In  1916,  the  state  spent  in  subsidies 
to  hospitals,  for  its  tuberculosis  work,  for  the  State  Department  of 
Health,  the  Mothers'  Assistant  Fund,  institutions  for  the  care  of 
defectives,  and  for  medicfilBUppllies'in  a^mslioiises  and  out-door  relief 
to  sick  persons,  over  .flO^OOO^OflO.  Of  this  sum,  imare  than  |6,000,000 
was  expended  for  the  work  df  tthe  State  Department  of  Health  and 
for  hospitals,  meclical  supplies  aaid  relief  in  inflividudl  cases  of  sick- 

{i)Lieutenant  Col^el  'H.  E.  Mock,  "Human  Salvage." — The  Nation's  "Business,  'Januarj'. 
1919,  p.   61. 

(2) Report  of  PerttiBylvanla  State  Board  o!f  (.Hertltl),   1887,  page  36fl. 


105 

ness,  while  a  large  proportion  of  the  remaining  |4,000,000  undoubt- 
edly went  to  pay  for  the  consequences  of  the  prevalence  or  the  neglect 
of  disease. 

The  ten  state  hospitals  for  miners  spent  |439,428.92  during  the 
calendar  year,  1916.  Of  this  amount  .f369,456.25  came  from  legisla- 
tive appropriation.  Out  of  14,451  in-patients  treated  in  that  period, 
12,617  or  87.3  per  cent.,  received  free  treatment.  In  addition,  there 
were  15,503  dispensary  patients  from  whom  but  |53.50  was  received 
for  treatment.    The  total  cost  of  free  treatment  was  |366,955.60.^ 

In  the  year  ending  May  31,  1916,  175  other  hospitals  made  statis- 
tical returns  to  the  State  Board  of  Charities.  During  the  year  they 
spent  17,937,055.10,  of  which  |2,351,723.96  was  received  from  the  state 
and  from  counties  and  cities,  and  |3,268,287.16  from  patients  for 
board  and  treatment.  In  spite  of  state  assistance,  102  of  these  hos- 
pitals reported  deficits  for  the  year  amounting  to  |743,486.49.  Of 
the  219,834  in-patients  reported,  127,678,  or  more  than  51  per  cent., 
had  been  treated  free.  The  total  number  of  free  hospital  days  was 
J  .627,346,  or  40.6  per  cent,  of  the  total  nuniher  of  days  of  treatment^ 
and  cost  almost  three  and  a  half  million  dollars.  There  were  also 
873,444  dispensary  patients,  whose  payments  for  treatment  amounted 
to  but  183,727.81,  or  less  than  ten  cents  each.^ 

Two  classes  of  tuberculosis  sanatoria  receive  funds  from  the  state. 
There  is  the  state  organization  under  the  Department  of  Health 
which,  in  1914,  controlled  116  dispensaries  scattered  throughout  the 
state  and  three  sanatoria  at  Mont  Alto,  Cresson  and  Hamburg. 

Every  year  more  than  15,000  persons  receive  either  free  dispensary 
or  sanatorium  treatment  at  a  cost  which  in  1916  amounted  to  |1,692,- 
690 — over  half  the  expenditures  of  the  Department  of  Health.  In 
addition,  the  dispensaries  secure  charitable  relief  for  the  families 
under  their  care,  which  each  year  amounts  to  between  |20.000  and 
$25,000.  About  half  this  sum  is  secured  from  the  County  Commis- 
sioners and  the  remainder  from  private  agencies  and  individuals. 

In  addition,  the  legislature  appropriated,  for  the  year  ending  May 
31,  1916,  subsidies  amounting  to  .f.50,500  for  nine  smaller  institu- 
tions for  the  treatment  of  tuberculosis  under  private  control,  whose 
total  expenditures  were  |263,108.11.  Altogether  the  nine  treated 
1.098  in-patients,  of  whom  almost  60  per  cent,  received  free  treat- 
ment to  the  amount  of  57,734  free  hospital  days.  They  also  cared 
for  5,273  dispensary  patients,  practically  all  of  whom  received  free 
treatment.^ 

Altogether  these  institutions  for  sickness-care,  exclusive  of  the 
State  Tuberculosis  Sanatoria,  spend  annually  over  |8,000,000  of 
which  almost  one-third  is  supplied  directly  by  state  funds.     They 


P)See  Tahle  VTII  r.t  tho  end  of  this  section. 
(2)  See  Tahle  IX  at  the  enrl  of  this  section. 
(^)See  Table  X  at  the  end  of  this  section,. 


106 

represent  a  real  estate  investment  of  over  |36,000,000,  endowments  of 
almost  115,000,000,  and  fixed  indebtedness  of  four  and  a  half  million. 
The  potential  annual  income  from  this  invested  capital  would  amount 
to  over  two  and  a  half  million  dollars.  During  1916,  of  1,124,330 
patients  treated,  140,944  were  free  in-patients,  94,439  paid  for  treat- 
ment, and  888,947  were  dispensary  patients.  The  receipts  from 
patients  for  treatment,  for  the  use  of  ambulance,  laboratory  facili- 
-  ties,  etc.,  amounted  to  |3,804.159.67,  while  the  total  cost  of  the 
1 ,925,921  free  hospital  days  was  |3,454,799.65. 

Still  another  way  in  which  public  funds  are  spent  sfor  medical 
charity  and  for  the  care  of  sick  employees  is  through  almshouses  and 
public  relief  in  almshouse  districts.^  Even  in  years  of  great  indus- 
trial depression,  "temporary  sickness  and  death"  is  the  principal 
cause  for  which  sucH  relief  is  given.  Over  a  five-year  period  it  ac- 
counts for  from  one-third  to  nearly  one-half  of  all  the  cases  relieved. 
8uch  relief  cost  in  1916,  |708,752.10.  In  addition,  eighty  almshouses 
reported  the  expenditure  of  |51,258.73  for  medicines  and  medical 
supplies. 

These  heavy  drains  upon  the  charitable  resources  of  the  state  indi- 
cate plainly  that  under  present  conditions  many  employees  are  not 
able  to  meet  the  expenses  of  sickness.  Much  of  the  relief  that  is 
given  has  little  or  no  preventive  or  curative  value,  because  the  hos- 
pital, the  dispensary,  or  the  county  almshouse  has  been  resorted  to 
only  after  a  seemingly  slight  ailment  has  become  a  serious  and  often 
incurable  disability,  and  the  worker  and  his  dependents  have  been 
forced  from  their  rightful  position  of  economic  indei)endence.  Past 
experience  has  demonstrated  that  any  plan  for  meeting  the  sickness 
prohlem  satisfactorily  must  furnish  a  stimulus  for  prompt  preventive 
effort  on  the  part  of  all  elements  concerned,  instead  of  providinff 
merely  institutional  and  charitaMe  means  of  care. 

Cost  of  Sickness  to  Private  Funds. 

While  it  has  been  impossible  to  obtain  accurate  and  complete 
figures  as  to  the  burden  imposed  on  private  charity  by  the  sickness 
of  wage  earners,  it  is  obvious  that  it  is  a  heavy  one.  There  is  a 
veritable  network  of  medical  charities  in  every  large  city,  including 
dispensaries,  hospitals,  special  clinics,  convalescent  homes,  and 
agencies  for  nursing-care  in  the  home.  In  a  single  year  in  twenty- 
seven  representative  hospital  social  service  departments  in  the  state, 
more  than  37,000  families  were  treated.  The  situation  in  Philadel- 
I)hia  is  typical.  In  the  "Reference  Book  of  Social  Agencies"^  which 
does  not  claim  to  be  complete,  there  are  listed  the  names  of  ten  gen- 
eral dispensaries,  in  addition  to  the  dispensaries  and  clinics  for 
special  kinds  of  treatment,  and  thirty-two  general,  and  thirty  special 
hospitals  of  various  kinds,  which  contain  free  beds  and  in  most  cases 


(i)See  Table  XII  at  end  of  this  section. 

(2)PubIished  by  The  Mtmicipal  Cptjrt,  Philadelphia,  191Q, 


107 

dispensary  facilities.  The  Visiting  Nurse  Society  of  Philadelphia 
alone  spent  in  1917  over  |41,800/  receiving;  but  |9,648.09  from  pati- 
ents in  fees,  leaving  more  than  77  per  cent,  of  its  budget  as  contribu- 
tions from  private  charity.  This  percentage  is  over  75  in  the  budgets 
of  the  private  dispensaries  studied.  In  no  case  did  the  receipts  from 
patients  equal  one-fourth  of  the  total  dispensary  expenditures  for 
one  year. 

At  the  present  time  there  is  no  way  of  estimating  the  probable 
cost  to  physicians  of  medical  care  given  by  them  either  at  reduced 
rates  or  wholly  free,  but  we  know  that  the  proportion  of  charity 
practice  among  physicians  is  very  large. 

The  problem  of  estimating  the  proportions  of  the  budgets  of  gen- 
eral relief  agencies  expended  because  of  sickness  is  even  more  diflScult 
and  subtle.  The  interplay  of  various  factors,  such  as  bad  housing, 
low  wages,  undernourishment^  unemployment  and  ill  health,  often 
creates  a  state  of  dependency,  in  which  it  is  impossible  to  single  out 
any  one  as  the  principle  cause.  Social  workers  generally  agree,  how- 
ever, that  illness  is  the  greatest  single  handicap  in  the  families  with 
whom  they  come  in  contact;  and  some  go  so  far  as  to  name  the  dif- 
ferent portions  of  their  budgets  expended  primarily  on  this  account. 
For  example,  one  relief  agency  states  that  nine-tenths  of  the  sum 
expended  for  relief  in  1917  was  spent  on  account  of  sickness.  Other 
societies  claim  lower  proportions.  A  study  of  the  yearly  budgets  of 
one  large  relief  society  in  Philadelphia,  which  analyses  its  expend- 
itures according  to  the  primary  causes  of  dependency  and  the  nature 
of  relief  given,  shows  ihnt  more  than  55  per  eeni.  of  the  actual  ex- 
penditures during  the  last  five  year's  have  been  hecause  of  illness,  and 
57  per  cent,  of  this  amount  because  of  tuberculosis. 


Year. 


£5 

S5 

5^ 

§2 

2a 

l§ 

St: 

-a 

•o 

°s« 

a 

Q,S 

c2o 
S5g 

s'"i 

S  *" 

w^S 

feS^ 

6 

Plh 

81 


isi 


1^^ 


1913-14,   

1915-18*   ""      "      "                                  "            "                                      

$17,912  09 
22,934  35 
23,877  98 
23,836  00 
23,539  21 

60* 

50 

50 

60 

65 

49 
49 

67 

1916-17, -_- 1 

64 
65 

Total  for  five  year  period               -      . 

$112,100  23 

57% 

55% 

(1)  This  IS  eliminating  the  oost  of  nursing  service  to  the  policy-holders  of  the  Metropolitan  lafe 
Insurance  Company,   which  is  paid  by  the  company  and  amounted  in   1917   to   $19,132.50. 

It  is  because  sickness  plays  such  a  large  part  in  pulling  down  into 
dependency  the  family  which  can  only  be  self-supporting  while  moder- 


108 

ately  healthy,  that  we  have  discussed  sickness  in  its  relation  to  family 
income  at  such  length,  in  the  section  following. 

The  cost  of  sickness  to  society  is  well  illustrated  by  the  case  of 
Mr.  Callahan.  Mr.  Callahan  was  a  tailor,  who  had  worked  for  a 
prominent  Philadelphia  firm  for  several  years.  He  was  the  father 
of  four  small  children.  Living  up  to  the  level  of  his  income,  with 
small  savings,  he  felt  he  could  not  afford  to  be  sick.  He  contracted 
tuberculosis,  due  undoubtedly  in  part  to  the  industrial  conditions  in 
which  he  worked.  He  denied  that  he  was  sick  and  dosed  himself 
continually  with  a  patent  medicine,  warranted  to  "cure  all  ills.'' 
Finally,  after  a  bad  hemorrhage,  he  gave  up,  ^ind  when  examined  he 
was  diagnosed  an  advanced  case  of  tuberculosis.  The  family,  up  to 
this  time  always  self-supporting,  became  dependent  upon  charity. 
One  of  his  former  employers  gave  |1.00  as  matter  of  charity;  the 
others  gave  nothing.  The  children  were  all  young,  and  Mrs.  Callahan 
could  not  leave  them  to  go  out  to  work.  Two  of  them  were  found 
to  be  tubercular.  Mr.  Callahan  was  only  thirty-eight,  and  the  family 
had  no  resources  for  the  long  future  that  loomed  ahead.  He  was 
sent  to  Mont  Alto,  where  little  hope  is  given  for  his  recover;  and 
for  the  past  three  years  the  family  has  been  cared  for  entirely  by 
private  philanthropy,  at  an  expense  of  many  hundreds  of  dollars. 
The  oldest  child  is  now  only  eleven.  Meantime  the  state  supports 
Mr.  Callahan  in  a  public  sanitorium.  Has  this  been  cheap  for  public 
or  private  funds,  or  for  society  at  large?  The  community  has  lost 
a  self-supporting  industrious  citizen ;  industry  has  lost  the  productive 
energy  of  a  good  worker;  Mr.  Callahan  has  lost  his  earning  power 
and  his  home;  the  children  have  suffered;  the  normal  family  unit 
has  been  permanently  broken  up. 

The  cost  of  adequate  measures  to  protect  health  will  be  repaid  a 
hundred  fold.     Society  could  make  no  better  investment. 

SICKNESS  AND  POVERTY. 
The  whole  problem  of  sickness  among  wage  earners'  families  hinges 
on  the  problem  of  poverty.  Sickness  is  both  a  cause  and  a  result  of 
poverty.  Too  often  it  is  at  bottom  the  condition  of  poverty  which 
has  caused  the  initial  sickness;  fear  of  more  poverty  which  prevents 
I>rompt  ti^atment;  continued  sickness  which  produces  more  poverty, 
and  so  on.  Jacob  Hollander  has  said  that  poverty  is  applied  indif- 
ferently to  three  distinct  conditions:  (1)  economic  inequality,  (2) 
economic  insufficiency,  and  (3)  economic  dependence.  "Economic 
inequality"  has  little  significance  for  our  purpose;  but  "economic 
insufficiency" — the  problem  of  that  group  midway  between  those  in 
comfortable  circumstances  and  the  out-right  dependent — the  propor- 
tion which  is  inadequately  fed,  clad,  and  sheltered — and  "economic 
dependence"  both  foster  and  are  fostered  by  disease. 


109 

It  is  impossible  to  give  exact  "causes"  for  poverty.  Schools  ot 
thought  swing  from  theories  of  land  and  capital  to  the  laissez-faire 
philosophy  of  individualism.  So  it  is  difficult  to  place  the  entire 
responsibilty  on  the  illness  of  any  given  family,  for  usually  the  inter- 
play of  various  factors  such  as  bad  housing,  low  wages,  undernourish- 
ment, unemployment  and  ill  health,  have  worked  together.  One  has 
often  caused  the  other.  For  instance,  in  an  unemployment  survey 
in  1915  covering  a  million  wage  earners,  11  per  cent,  of  the  unem- 
ployment had  been  caused  by  sickness  or  accident.  Yet  sickness 
seems  to  be,  without  question,  the  principal  single  factor  which  serves 
as  the  "last  straw,"  and  more  often  than  any  thing  else  forces  the 
ordinary  wage  earner's  family  to  seek  help  outside  his  own  re- 
sources. 

The  story  of  the  Murphy  family  well  illustrates  the  typical  course 
of  events : 

The  Murphy s  had  lived  in  Philadelphia  for  seventeen  years  and  there 
were  six  little  Murphys,  all  under  working  age.  Neither  Mr.  nor 
Mrs.  Murphy  had  ever  been  strong,  and  their  constant  ill  health  w^as 
reflected  in  Mr.  Murphy's  work  and  Mrs.  Murphy's  housekeeping. 
The  children  were  ailing,  and  did  not  have  the  proper  nourishment. 
Mr.  Murphy  made  about  |20.00  a  week  Avhen  he  could  work  full 
time,  and  Mrs.  Murphy  attempted  to  add  to  this  by  taking  in  two 
men  boarders,  as  she  could  not  go  out  for  days'  work,  while  the 
children  were  so  young.  She  was  advised  that  she  needed  an  opera- 
tion badly,  but  she  thought  it  best  to  go  on  working  and  forget  she 
felt  so  ill,  as  it  would  be  utterly  impossible  for  her  to  have  this 
medical  attentldii.  For  some  time  they  managed  to  get  along,  but 
finally  Mr.  Murphy  was  threatened  with  tuberculosis  and  the  bills 
increased.  The  doctor  advised  a  change  in  work,  but  he  had  been 
with  the  same  firm  for  fourteen  years,  had  a  good  work  record,  and 
hoped  he  was  near  a  promotion.  This  firm  paid  a  sick  benefit  after  a 
waiting  period  of  three  days,  but  it  was  only  |.40  a  day,  and  what 
was  that  Avith  six  children?  As  long  as  he  could  possibly  keep  up, 
he  felt  he  must.  Besides  this,  he  belonged  to  a  Fraternal  paying  a 
sick  benefit,  but  this  was  paid  only  after  a  waiting  period  of  two 
weeks,  and  there  were  many  restrictive  rules  and  assessments.  They 
were  anxious  to  keep  this  membership  up,  however,  on  account  of 
the  substantial  death  benefit.  Mr.  Murphy  tried  not  to  miss  more 
than  a  day  or  two  at  a  time,  from  his  work,  and  the  family  spent 
sometimes  as  much  as  flO.OO  a  week  on  patent  medicines.  Things 
seemed  more  expensive  with  the  boarders  than  without,  and  they 
gave  up  this  plan  of  eking  out  their  income. 

Then  Mr.  Murphy  broke  down,  and  was  ill  for  five  weeks.  They 
borrowed  some  money  from  a  sister  and  the  doctor  reduced  his  rates. 
In  spite  of  this  they  found  themselves  with  a  rent  bill  of  |18.00, 


110 

a  store  bill  of  |i55.00,  a  luilk  bill  of  |42.00,  and  a  doctor's  bill  of 
over  170.00,  and  on  top  of  this  the  advice  that  Mr.  Murphy  was  to 
have  "fresh  eggs  and  plenty  of  milk  every  day." 

Their  savings  were  gone,  they  could  obtain  no  more  credit;  rela- 
tives were  unable  to  help  them  longer,  and  so  they  sought  a  money- 
lender, and  borrowed  |50.00  at  10  per  cent,  a  month.  This  was  only 
a  drop  in  the  bucket,  and  the  interest  was  very  difficult  to  meet. 
The  loan  agency  took  advantage  of  the  situation  and  continued 
charging  them  for  three  months  after  they  had  paid  the  money  back. 

Mr.  Murphy  went  back  to  work,  far  from  well;  he  had  not  been 
able  to  secure  the  sick  benefit  from  his  lodge  because  he  was  a  month 
behind  in  his  dues.  The  family  could  never  get  ahead.  Mrs.  Murphy 
tried  to  take  in  extra  work  and  do  it  at  night  after  the  children  were 
in  bed,  but  could  not  stand  the  strain.  Things  went  from  bad  to 
worse,  and  finally  Mrs.  Murphy,  worn  out,  discovered  she  could  take 
the  baby,  who  was  ill,  to  the  Hospital  dispensary  and  secure  medical 
advice  free  for  the  child  and  for  herself.  The  doctor  there  realized 
that  she  was  in  critical  need  of  attention  and  that  the  whole  family 
were  suffering  from  a  chronic  struggle  with  ill  health  gjid  inability 
to  secure  medical  care  or  follow  a  physician's  orders,  and  conse- 
quently referred  her  to  a  private  organization  from  which  she  could 
secure  help.^ 

The  Murphys  are  not  unlike  hundreds  of  other  families.  Theirs 
was  the  typical  road  from  independence  to  dependence.  Wages  at 
the  present  time,  with  the  cost  of  living  as  it  is,  do  not  cover  risks. 
Sickness  is  a  risk,  and  the  average  wage-earner  trusts  his  lucky  star 
that  he  may  escape  it.  The  problem  is  largely  an  economic  one.  The 
amount  a  man  can  save  depends  upon  the  amount  of  his  income,  far 
more  than  upon  his  personal  volition.  Saving  toward  an  emergency 
is  not  only  difficult,  but  impossible,  if  his  income  admits  bare  suffi- 
ciency. On  the  other  hand,  the  amount  of  family  income  determines 
in  large  measure  the  standard  of  living  possible,  which  in  turn 
directly  effects  the  susceptibility  to  disease  and  the  power  of  re- 
sistance against  it.  "You  can  kill  a  man  with  a  tenement  as  easily 
as  with  an  axe,"  Jacob  Riis  says. 

Over-crowding,  foul  air,  lack  of  light,  can  but  breed  disease.  Yet 
how  is  the  average  wage  earner  in  an  industrial  community  to  obtain 
the  room,  light,  air,  and  nourishing  food,  essential  to  the  good  health 
which  is  his  greatest  asset?  And  when  he  once  becomes  ill,  how  can 
he  afford  to  obtain  medical  care  quickly,  and  follow  the  doctor's 
orders? 

Not  only  does  the  wage  earner  himself  suffer,  but  the  family,  and 
particularly  the  children,  bear  the  brunt  of  th^  strain.    We  know  the 


(*)In  all  cases  of  families  whose  stories  are  told  the  names   and  initials  are  assumetl. 


Ill 

lasting  effects  which  a  period  of  privation  has  on  children.  Under- 
nourishment, coming  in  many  instances  from  "economic  insufficiency'' 
due  to  a  period  of  illness  and  an  attempt  to  "make  ends  meet," 
is  one  of  the  "original  and  basic  defects"  found  in  the  examination 
of  school  children.  In  a  study  of  171,G91  children  made  in  the  Bor- 
ough of  Manhattan  in  December  1917,  only  17.3  per  cent,  of  these 
children  were  found  to  be  in  a  normal  condition  so  far  as  nutrition 
was  concerned.  Sixty-one  per  cent,  were  "borderline  cases ;"  18.5  per 
cent,  were  definitely  undernourished  and  needed  immediate  atten- 
tion, and  3.1  per  cent,  were  advanced  cases  of  undernourishment 
needing  immediate  medical  care. 

In  our  own  state,  in  Philadelphia,  of  5,621  children  between  four- 
teen and  sixteen  years  of  age  examined  for  employment  certificates 
in  the  first  six  months  of  1916,  20  per  cent,  had  defects  debarring 
them  from  immediate  certificates. 

How  much  of  this  is  the  result  of  privation  coming  because  of  ill- 
ness in  the  family,  it  is  impossible  to  estimate.  Ignorance,  com- 
m.unity  standards^  working  conditions,  all  play  a  large  part,  but  the 
emergency  of  illness  is  one  of  the  prime  factors.  Here  then,  is  the 
gist  of  the  problem — there  are  not  adequate  means  in  this  country 
to-day,  by  which  the  wage  workers  can  safeguard  himself  and  his 
family  against  a  possible  emergency,  such  as  sickness. 

A  study  of  wage  conditions  shows  that  the  great  majority  of  wage 
earners'  families  can  be  self  supporting  only  so  long  as  they  are 
moderately  healthy.  When  sickness  comes,  they  must  have  relief,  if 
not  from  one  source,  from  another,  and  the  more  prolonged  the 
sickness,  the  greater  the  delay  in  securing  care  in  the  beginning,  the 
greater  must  be  the  amount  of  relief. 

Of  the  thousands  of  families  who  obtain  sufficient  help  from  their 
friends  and  relatives  to  see  them  through,  or  who  live  on  credit  or 
their  own  savings  during  illness,  ^e  have  little  knowledge.  Surveys 
show  that  practically  all  families  exhaust  these  resources  before  ob- 
taining public  or  private  aid.  We  do  know,  however,  that  sickness 
drives  large  numbers  to  borrow  from  loan  societies  of  various  sorts, 
and  that  this,  as  in  the  case  of  the  Murphy  family,  is  often  one  of  the 
first  steps  toward  dependency. 

In  a  study  of  the  loans  made  in  one  year  by  twenty-two  remedial 
loan  societies  in  as  many  different  cities,  an  attempt  was  made  to 
ascertain  the  proportion  of  the  loans  where  sickness  was  given  as  the 
reason  for  borrowing.^  In  two  cases  the  societies'  records  were  kept 
in  such  a  way  that  the  actual  percentage  could  be  given — 14  per 
cent,  in  one  case,  37  per  cent,  in  the  other.  In  seventeen  other  cases 
an  "estimated  proportion"  was  given,  which  ranged  from  10  per  cent. 

(i)Thi'^  study  was  made  available  through  the  kindness  of  the  Ohio  Health  and  Old  Age  In- 
surance CommlBsion. 


112 

to  75  per  cent.  The  low  percentag^es  made  because  of  sickness  were 
in  cases  where  the  number  of  pledge  loans  made  by  the  society  was 
very  large.  The  average  percentage  was  apparently  over  38.  In  one 
of  the  three  cases  where  no  estimate  was  given,  the  percentage  due 
to  sickness  was  termed  "very  large/'  in  another  case  they  reported: 
"Scarcely  a  day  but  what  a  loan  is  made  to  pay  the  expense  of  an 
operation,  hospital  bill,  etc.,  and  in  most  cases  the  failure  to  meet 
the  contract  is  due  to  sickness."  Another  society  says  "sickness  is 
the  reason  given  for  non-payment  in  95  per  cent,  of  our  defaults." 

The  average  size  of  the  99,555  loans  made  by  the  nineteen  of  these 
societies  for  which  figures  were  obtainable  was  only  |49.30.  This  is 
considerably  less  than  the  average  loan  made  by  the  Morris  Plan 
Banks,  which  are  established  in  104  cities  in  the  United  States  to 
meet  the  needs  of  the  industrial  worker  who  so  seldom  has  banking 
connections.  In  the  Morris  Plan  Company  in  New  York,  44,866  loans 
were  made  between  January  1, 1915,  and  June  30,  1917.  Of  these,  593 
were  under  |25.00;  13,140  were  between  $25.00  and  |50.00,  987 
were  between  |50.00  and  |75.00  and  17,367  were  between  175.00  and 
$100.00.  Thus  some  70  per  cent,  of  all  the  loans  were  under  flOO.OO 
and  30  per  cent,  were  under  $50.00. 

The  weekly  income  of  the  men  and  women  borrowing  from  the 
Morris  Plan  Company  averaged  $26.00,  bespeaking  a  group  of  wage 
earners  a  little  above  the  ordinary ;  the  largest  numbers  classified  by 
occupations  were  clerks,  salesmen,  owners  and  partners,  while  fac- 
tory hands,  tailors,  machinists,  etc.,  were  relatively  few.  From 
January  1,  1917,  to  June  30,  1918,  12,300  loans  had  been  made  where 
the  reason  given  for  borrowing  was  "illness  and  births."  Seven 
hundred  and  se^^^enty  more  loans  were  made  because  of  death  in  the 
family.  The  "illness  and  births"  classification  outnumbered  any 
other  single  classification  by  over  4,000  and  formed  almost  16  per  cent, 
of  the  total  loans  made.  This  classification  did  not  by  any  means 
include  all  the  loans  made  where  illness  was  a  factor,  as  other  classi- 
fications include  "Repay  loan  sharks,"  "Pawns  and  chattels,"  "Mis- 
cellaneous debts,"  "Help  relatives,"  etc.,  where  many  of  the  first  debts 
have  doubtless  been  contracted  because  of  illness.  In  connection 
with  this  it  is  interesting  to  ndte  a  letter  from  one  of  the  Morris  Plan 
Company  borrowers.  "A  few  years  ago,"  he  writes,  "owing  to  sick- 
ness in  my  family,  I  was  compelled  to  go  to  a  loan  shark  to  borrow 
money.  From  that  time  on  things  grew  from  bad  to  worse,  and  falling 
behind  in  my  payments  I  was  subjected  to  such  unmerciful  persecu- 
tion that  I  was  on  the  verge  of  committing  suicide." 

The  only  Morris  Plan  Company  in  Pennsylvania  is  in  Philadelphia, 
and  it  is  unfortunate  that  their  records  have  not  been  kept  in  the 
same  way  as  those  in  New  York.  Statistics  for  the  past  nine  months, 
however,  January  1,  1918,  to  September  30,  1918,  were  tabulated 


iia 

especially  for  the  Commission.  During  these  nine  months  135  loans 
had  been  made  where  the  borrower  gave  illness  as  his  reason  for 
needing  the  money.  Five  more  loans  were  made  because  of  death. 
The  borrowers  in  119  cases  had  families  dependent  on  them ;  in  seven- 
teen cases  they  were  men  or  women  with  no  dependents.  The  income 
of  these  borrowers  was  known  in  133  cases.  In  eighty-six  cases,  or 
64  per  cent,  the  weekly  income  was  between  |15.00  and  |25.00.  In 
forty  more  cases,  or  30  per  cent.,  it  was  between  |26.00  and  |40.00. 
In  only  six  cases  was  it  over  $40.00  a  week,  and  in  only  one  case  was 
it  under  |15.00  a  week.  This  is  an  interesting  contrast  to  the  incomes 
of  the  groups  who  have  passed  the  stage  of  "borrowing"  and  have 
dropped  into  dependency.  The  Company  does  not  lend  less  than 
150.00,  and  we  find  that  twenty-nine  of^the  loans  were  for  that 
amount.  Seventy,  or  exactly  50  per  cent.,  were  for  flOO.OO  and 
only  twelve  exceeded  the  |200.00  mark.  The  largest  loan  made  be- 
cause of  illness  was  one  for  $300.00. 

So  much  for  those  who  have  tided  over  the  emergency  of  sickness 
by  borrowing  money  on  a  personal  or  business  basis.  Much  more  can 
be  said  of  those  who  have  passed  to  the  next  stage — that  of  economic 
f'ependence.  In  how  many  cases  of  the  thousands  coming  to  the  gen- 
eral relief  societies  asking  for  help,  has  sickness  been  the  determining 
factor  in  the  application  ? 

Edward  T.  Devine,  the  head  of  the  New  York  Charity  Organiza- 
tion Society  says: 

"111  health  is  perhaps  the  most  constant  of  the  attendants  of  pov- 
erty. It  has  been  customary  to  say  that  26  per  cent,  of  the  distress 
know^n  to  charitable  societies  is  caused  by  sickness.  An  inquiry  into 
the  physical  condition  of  the  members  of  the  families  that  ask  for 
aid,  without  for  the  moment  taking  any  other  complication  into  ac- 
count, clearly  indicates  that  whether  it  be  the  first  cause  or  merely  a 
complication  from  the  effect  of  other  causes,  physical  disability  is  at 
any  rate  a  very  serious  disabling  condition  at  the  time  of  application 
in  three-fourths — not  one-fourth — of  all  the  families  that  come 
under  the  care  of  the  Charity  Organization  Society,  who  are  prob- 
ably in  this  respect  in  no  degree  exceptional  among  families  in  need 
of  charitable  aid."^ 

In  special  studies  made  by  the  Social  Insurance  Commissions  of 
California  and  of  New^ersey^  sickness  was  the  "primary  cause"  of 
the  dependency  in  50  per  cent,  of  the  5,000  cases  studied  in  California 
and  42  per  cent,  of  the  1,412  cages  studied  in  New  Jersey. 

In  a  study  made  in  1909  of  31,481  dependent  cases  by  the  United 
States  Immigration  Commission,  sickness  was  a  factor  in  producing 
the  dependency  of  over  38  per  cent.,  whereas  accident  was  a  factor 
in  but  3.9  per  cent. 


(1)  Edward  T.   Devine,   Misery  and  its  Causes,  page  54. 


114 

In  our  own  state  the  same  general  conclusions  are  borne  out.  In 
considering  sickness  as  a  factor  in  producing  public  dependents,  it 
is  impossible  even  to  estimate  the  number  of  almshouse  inmates  whose 
entrance  may  be  traced  to  such  a  cause.  The  almshouses  of  the  state 
do  not,  as  a  rule,  however,  care  why  their  inmates  have  come.  The 
stewards  are  men  who  are  not  likely  to  be  concerned  with  the  econ- 
omic and  social  causes  underlying  the  applications  for  admission. 
The  Board  of  Public  Charities,  however,  attempts  to  classify  the 
outdoor  relief  given  throughout  the  state,  by  the  primary  cause  of 
destitution.  The  records  for  this  administration  of  outdoor  relief 
are  enlightening.  Over  a  period  of  five  years  "temporary  sickness  or 
death"  has  always  stood  first  as  a  problem  of  dependency.  The  per 
cent,  varies  in  each  year  from  35.70  to  47.33.  "Want  of  work''  comes 
next,  accounting  for  from  8.70  to  25.8^  per  cent.,  and  the  remaining 
cases  are  attribuated  to  old  age,  desertion,  intemperance,  insanity  or 
feeblemindedness,  and  miscellaneous  causes.^ 

If  this  is  true  of  the  outdoor  delief,  it  is  probably  even  more  true 
of  almshouse  inmates. 

If  we  take  the  group  coming  to  the  private  general  relief  societies, 
we  find  that  here  too,  sickness  has  been  by  far  the  greatest  single 
factor  in  producing  the  dependency.  If  we  reverse  our  point  of  view 
and  take  the  group  seeking  free  medical  aid  we  find  that  temporary 
financial  dependency  is  the  greatest  single  factor  in  driving  them 
there.  In  a  study  made  by  one  of  the  Hospital  Social  Service  Depart- 
ments of  Philadelphia  of  1,050  cases  coming  to  them  between  January 
and  June,  1918,  the  group  of  those  "temporarily  financially  depend- 
ent" out-numbered  all  others  by  almost  two  to  one,  so  that  either 
way  you  look  at  it,  the  statement  holds  good. 

In  a  letter  to  the  Commission,  Mr.  Karl  de  Schweinitz,  the  General 
Secretary  of  the  Philadelphia  Society  for  Organizing  Charity  says: 

"Sickness  is  the  greatest  single  handicap  affecting  the  families 
under  the  care  of  the  Society  for  Organizing  Charity.  Unemployment 
may  vary  in  amount  from  season  to  season,  but  year  in  and  year  out 
ill-health  continues  to  undermine  the  working  efficiency  of  wage- 
earners,  to  prevent  mothers  from  taking  proper  care  of  home  and 
children,  and  to  cause  boys  and  girls  to  be  irregular  in  school  at- 
tendance and  inferior  in  capacity  to  learn. 

"Much  of  this  sickness  is  preventable.  Much  more  could  be  ren- 
dered comparatively  unimportant  if  treatment  were  i)romptly  avail- 
able. Only  too  often,  however,  the  sick  throw  away  their  chances 
for  speedy  cure  by  continuing  at  work  because  they  cannot  afford  to 
lose  pay  by  staying  at  home.  Again  and  again,  also,  we  find  that 
families  have  postponed  sending  for  a  doctor  in  the  hope  that  the 
patient  would  recover  without  making  necessary  the  incurring  of  an 

(»)See  Table  XII  at  the  end  of  this  section. 


115 

expense  which  they  have  not  the  money  to  meet.  Nothing  perhaps 
v/ould  help  so  much  to  reduce  sickness  among  small  wage-workers 
as  prompt  medical  treatment  and  cessation  from  work  when  the  first 
symptoms  of  disease  appear." 

A  study  of  the  cases  coming  to  the  United  Hebrew  Charities  of 
Philadelphia  show  that  for  the  last  five  years,  sickness  has  figured 
as  the  main  problem  in  each  year's  work.  In  1913-14,  these  cases 
formed  46  per  cent,  of  the  760  cases  handled ;  in  1914-15,  39  per  cent, 
of  the  1,189  cases ;  in  1915-16,  56  per  cent,  of  the  870  cases;  in  1916-17, 
05  per  cent,  of  the  557  cases ;  and  in  1917-18,  63  per  cent,  of  the  444 
cases. 

Even  in  1914-15,  the  year  of  the  unemployment  panic  when  the 
sickness  cases  dropped  to  39  per  cent.,  unemployment  was  given  as 
the  main  problem  in  but  22  per  cent. 

In  the  work  of  the  Bureau  for  Jewish  Children  the  illness  of  the 
parents  was  given  as  the  reason  for  application  in  49  per  cent,  of  the 
413  applications  in  1915-16,  and  in  51  per  cent,  of  the  472  applications 
in  1916-17 ;  the  number  applying  in  this  year  because  of  sickness  was 
six  times  as  great  as  the  number  applying  for  any  other  of  the  twenty- 
Fix  reasons  given. 

Through  the  kindness  of  the  Philadelphia  Bureau  for  Social  Ke- 
search  two  unpublished  studies  were  placed  at  the  disposal  of  the 
Commission.  Both  studies  covered  the  year  January  1,  1916  to  Janu- 
ary 1,  1917. 

The  first  study  dealt  with  the  condition  of  families  coming  to  the 
four  largest  relief  societies  in  Philadelphia;  the  total  number  of 
families  covered  by  the  smallest  society  was  included,  and  a  corres- 
ponding number  was  taken  from  each  of  the  other  three.  The  Bureau 
classified  these  applications  for  help  by  the  main  problem  involved, 
and  it  is  interesting  to  note  the  proportion  for  which  sickness  was 
responsible  in  these  four  societies:  16.59  per  cent.,  29.65  per  cent., 
31.15  per  cent.,  and  53.36  per  cent.  The  Bureau  states:  "Sickness 
is  proved  to  be  the  greatest  problem  to  be  met  by  all  of  the  agencies 
*  *  *  *  That  sickness  is  not  only  the  largest  contribution,  but  also 
the  problem  least  easily  solved,  is  shown  by  the  fact  that  it  forms 
a  larger  percentage  of  the  ^old  and  recurrent'  cases,  than  it  does  of 
the  new  applications.  For  instance,  in  one  society  it  formed  42.28 
per  cent,  of  the  new  applications,  and  64.81  per  cent,  of  the  recurrent 
cases,  during  this  year." 

The  second  study  of  the  Bureau  dealt  with  the  problem  of  child 
care,  when  sickness  in  the  family  made  outside  help  imperative.  The 
first  section  of  this  study  covered  208  families  where  children  under 
sixteen  were  removed  from  home  on  account  of  illness  in  the  family. 
The  figures  given  seem  to  indicate  that  by  far  the  greatest  number 
of  the  children  came  from  a,  normal  group  of  rather  low-wage  families, 


116 

About  70  per  cent,  were  from  homes  "where  there  was  no  disturbance 
of  marital  relation.  In  only  27.5  per  cent,  of  the  cases  was  the 
mother  the  main  bread-winner.''  The  families  did  not  seem  to  be  of 
abnormal  size,  nor  were  they  transients  or  recent  immigrants,  since 
S8  per  cent,  had  lived  in  Philadelphia  three  years  or  more. 

Sixty-two  per  cent,  of  the  heads  of  these  families,  however,  had 
weekly  wages  below  the  |11.00  which  was  the  average  weekly  wage 
in  the  manufacturing  industries  of  the  state  in  1916. 

Kegarding  the  exact  relation  of  the  existing  illness  to  the  depend- 
ency, the  report  states  that  "the  temporary  character  of  care  given  to 
children  removed  from  their  homes  indicates  the  fact  that  illness  in 
the  cases  studied  was  responsible  for  the  dependency,  and  that  a 
felight  amount  of  assistance  might  have  saved  the  children  from  re- 
moval. In  fact,  in  85  per  cent,  of  the  cases  the  sickness  of  one  or 
both  parents  appeared  as  the  sole  cause  of  removal.  Over  a  third 
of  the  children  were  away  from  their  homes  less  than  an  month,  and 
214  out  of  255,  when  discharged,  were  given  back  into  the  custody 
of  their  parents.  Nine  out  of  every  ten  of  the  childreii  had  never 
been  removed  from  home  before. 

"In  nine^tenths  of  the  families  one  or  both  parents — ^the  mother 
more  often  than  the  father — had  been  taken  to  a  hospital  or  other 
institution  for  care  a  very  short  time  before  the  children  were  re- 
moved." The  report  concludes  that  the  result  of  the  study  shows, 
beyond  a  doubt,  the  "limited  resources  for  emergencies  in  families 
both  economically  and  socially  normal."  It  would  appear  that  some 
systematic  method  of  meeting  the  wage-loss  of  employees  during  ill- 
ness and  of  providing  medical  care  for  them  and  their  wives  is 
needed  to  prevent  the  breaking  up  of  homes  which  illness  now  causes. 

The  second  section  of  the  study  deals  with  418  families  suffering 
from  illness  and  applying  to  the  Society  for  Organizing  Charity  or 
to  the  United  Hebrew  Charities  "for  relief  in  order  to  provide  proper 
care  for  the  children."  Here  again  we  find  a  group  of  normal  families 
"with  wages  no  different  from  the  average,  outside  the  highly  skilled 
trades."  In  71  per  cent  of  the  families  both  parents  were  living 
together;  14.6  per  cent,  more  were  families  of  widows  or  widowers, 
and  only  15.2  per  cent,  were  cases  of  separation,  desertion,  or  irregu- 
lar union. 

Many  of  the  men  were  fairly  steady  workers,  for  53  per  cent,  of 
those  who  were  employed  when  disabled  by  illness  had  worked  for  the 
same  employer  more  than  a  year.  Of  the  300  persons  whose  usual 
weekly  income  was  known,  the  largest  group,  43  per  cent,  received 
between  .«;10.00  and  |15.00  a  week.  But  at  the  time  charitable  relief 
was  given  them,  the  incomes  of  nearly  all  were  reduced  to  little  or 
nothing;  only  three  per  cent,  had  oyer  flO.OO  a  week  and  60  per 
cent,  had  ^JS.Qp  or  less. 


117 

This  bears  out  the  truth  of  the  fact  that  wages  do  not  cover  risks, 
and  that  savings  are  too  soon  exhausted  to  be  relied  upon  to  meet 
emergencies. 

Since  illness,  year  in  and  year  out,  forms  the  chief  single  factor 
in  the  creation  of  dependency,  it  has  seemed  wise  to  study  closely  a 
dependent  group  handicapped  by  illness.  Who  are  the  people  in  this 
group ;  what  are  their  standards ;  are  they  employees  of  an  ordinary 
type,  or  are  they  as  often  claimed,  a  special  "pauper"  class? 

Seven  cities  in  the  state,  through  their  Associated  Charities,  con- 
tributed to  this  study.  Detailed  information  regarding  the  families 
where  illness  was  a  problem,  was  secured  and  tabulated.^  In  all, 
1,584  families  containing  over  7,250  individuals  were  studied.  This 
does  not  pretend  to  represent  the  total  number  of  families  in  which 
illness  was  a  factor  in  the  dependent  group  coming  to  these  societies. 
They  reported  unanimously  that  illness  was  the  greatest  problem 
with  which  they  had  to  deal.  In  Reading  this  was  reported  as  the 
main  factor  in  the  dependency  of  41  per  cent,  of  the  families;  in 
Johnstown,  54  per  cent.,  in  New  Castle  44  per  cent.,  in  York  88  per 
cent.,  and  in  Sewickley,  90  per  cent.  In  Philadelphia  more  than  a 
third  of  the  families  needing  help  in  1914-15,  were  suffering  from 
illness,  and  some  42  per  cent,  in  1915-16.  In  1914-15,  the  great  year 
of  unemployment,  in  the  10,488  families  asking  aid  from  the  Phila- 
delphia Society  for  Organizing  Charity,  the  problems  of  unemploy- 
ment numbered  4,237,  while  the  illness  problems  were  3,867,  a  dif- 
ference of  but  870.  This  is  another  instance  of  the  fact  that  even  in 
a  panic  year,  where  one  reason  for  dependency  asserts  itself  so 
strongly,  sickness,  is  a  steady  factor. 

As  a  result  of  the  influenza  epidemic  224  new  families  needed  help 
from  the  Philadelphia  Society  for  Organizing  Charity,  in  October 
and  November  1918.  One  hundred  and  thirty-four  were  widows  who 
had  lost  their  husbands  in  the  epidemic.  The  otlier  families  had  ex- 
hausted their  own  resources  and  could  not  see  through  the  sickness 
emergency. 

Epidemics  are  spectacular  and  drive  home  truths.  Sickness,  how- 
ever, is  constant.  The  ranks  of  the  dependent  are  recruited  daily 
because  of  the  burden  imposed  wholly  on  the  individual,  through  it. 

The  group  requiring  charity  chiefly  because  of  sickness  are  in  the 
majority  of  cases  normal  families,  not  particularly  large.  But  in 
many  instances  the  children  are  young  and  cannot  work,  so  that  if 
the  bread-winner  falls  ill,  as  soon  as  their  resources  are  exhausted — a 
longer  or  a  shorter  time  according  to  whether  they  are  skilled  or  un- 
skilled, high  paid  or  low  paid — the  almost  inevitable  result  is  desti- 
tution and  an  appeal  to  charity.  This  is  particularly  true  if  the  wife 
expects  a  baby  and  so  is  unable  to  go  out  to  work. 


/I) The  families  were  tliose  dealt  with  by  the  Societies  during  their  last  fisoal  year. 


118 

Much  of  the  destitution  caused  by  illness  comes  at  a  time  when  it 
threatens  the  health  not  only  of  the  present  but  of  future  generations. 
We  all  know  that  expectant  mothers  must  have  proper  nourishment 
and  comparative  freedom  from  anxiety  to  protect  their  own  health 
and  that  of  their  babies,  and  that  a  period  of  privation  cannot  fail 
to  leave  a  permanent  mark  on  growing  children.  Some  organized 
system  of  maternity  heme  fit,  providing  prenatal  and  postnatal  care 
and  including  adequate  care  at  confinement  for  every  tvorking  mother 
and  the  tvife  of  every  employee,  is  needed  to  prevent  such  suffering 

Mr.  0.  was  a  teamster,  attempting  to  support  his  wife  and 

four  young  children  on  his  weekly  wage  of  |13.50.     He  was 

badly  poisoned  and  was  away  from  work  three  weeks,  having 

some  free  attention  from  a  private  physician.    His  wife  who 

was  pregnant  and  unable  to  go  out  to  work,  suffered  a  fall 

which  disabled  her  for  two  weeks.     She  had  had  no  prenatal 

care  and  was  now  attended  by  the  district  doctor  while  a 

relief  society,  together  with  relatives,  supported  the  family. 

One  or  two  cases  of  pauperized  families,  begging  and  immoral, 

were  found,  while  in  a  few  instances  the  need  was  created  by  old  age 

rather  than  illness,  and  occasionally  the  wife  or  children  might  not 

have  needed  charity  when  they  became  ill  if  the  husband  had  not 

deserted;  but  the  great  majority  of  the  families  were  not  of  such 

types. 

Seventy  and  three-tenths  per  cent,  of  the  Philadelphia  families 
were  "normal"  in  the  sense  that  either  the  father  and  mother  were 
living  together  and  the  father  was  the  main  support  of  the  family, 
or  that  adult  children  (over  eighteen)  were  supporting  widowed 
parents.  The  latter  group  covered  only  a  small  number  of  cases,  as 
the  most  distinctive  feature  abbut  these  families,  and  seemingly  the 
most  important  in  which  they  differed  socially  from  a  typical  group 
of  wage-earners  such  as  was  covered  by  the  Kensington  Survey,  was 
the  unusual  proportion  in  which  young  children  were  found.  This 
is  further  illustrated  by  the  fact  that  the  average  number  of  wage- 
earners  per  family,  1.75,  was  somewhat  lower  than  in  the  Kensington 
Survey. 

Certainly  the  families  could  not  be  considered  unusually  large. 
The  1,549  families  whose  size  was  known  averaged  but  4.7  persons. 
The  average  size  of  the  families  in  the  Kensington  Survey  was  4.r> 
persons,  and  the  "typical  family,"  according  to  "cost  of  living"  in- 
vestigators, is  five  persons.  Two  hundred  and  ninety-one  families 
consisted  of  only  one  or  two  persons,  and  793  of  three  to  six,  whicJi 
ordinarily  means  father,  mother,  and  one  to  four  children. 

The  following  cases  are  typical  of  the  many  in  which  illness  was 
the  only  apparent  handicap. 

Two  attacks  of  grippe,  each  lasting  two  weeks,  caused  Mr. 
H.  to  have  difficulty  in  meeting  his  family  expenses.  He  was  a 
clerk^  earning  about  flS.OO  a  week^  with  a  wife  and  six  young 


119 

children ;  the  oldest,  twins  of  ten  years.  His  wife  was  not  able 
to  help  the  family  by  outside  work,  since  she  had  a  "weak 
heart,"  and  was  soon  to  have  a  baby.  The  family  used  their 
savings,  but  those  were  soon  exhausted,  and  they  were  obliged 
not  only  to  have  help  from  relatives  and  their  church,  but  to 
apply  to  a  relief  agency. 

Ordinarily  the  D.  family  were  quite  comfortably  off,  with  the 
father  working  as  a  fireman  for  |18.00  a  week  and  the  oldest 
child  a  winder  in  a  textile  mill  at  |6.00.  But  when  Mr.  D. 
had  an  attack  of  erysipelas  and  had  to  spend  l;hree  months  in 
a  hospital,  the  earnings  of  the  fifteen-year  old  were  not  suffi- 
cient to  meet  the  needs  of  Mrs.  1).  and  the  three  younger 
children.  The  family's  savings  were  exhausted  in  two  months 
and  in  spite  of  the  fact  that  the  firemen  took  up  a  collection 
for  them,  they  had  to  get  help  from  several  different  chari- 
table sources. 
Occasionally  a  man  or  woman  living  alone  was  reduced  to  de- 
pendency following  an  attack  of  sickness. 

When  Mrs.  O.  was  well,  she  was  able  to  support  herself  in- 
dependently by  doing  house  work.  But  nine  weeks  of  disa- 
bility Qaused  by  a  broken  leg  rendered  her  dependent  on 
charity.  After  five  weeks  in  a  hospital  it  was  necessary  for 
her  to  spend  four  weeks  of  convalescence  in  an  almshouse 
under  the  care  of  the  district  "poor  doctor." 

Typically,  the  heads  of  the  families  were  employed  in  the  heavy 
hand  work  which  lies  at  the  foundation  of  the  city's  activities.  In 
Philadelphia,  about  35  per  cent,  were  engaged  in  some  sort  of  fac- 
tory work  or  hand  trade,  25  per  cent,  were  "laborers,"  and  nearly  20 
per  cent. — a  large  proportion  of  whom  were  w^omen — in  "domestic 
and  personal  service."  There  were  about  the  same  proportion  of  per- 
sons in  manufacturing  in  this  group,  as  there  were  in  the  whole  city 
in  1910,  more  laborers  and  domestic  workers  and  fewer  in  trade  and 
the  professional  and  clerical  groups — more,  in  short,  of  the  less 
skilled  and  more  poorly  paid  workers.  Outside  Philadelphia,  the 
percentage  of  laborers  and  domestic  workers  was  even  higher — 31.7 
per  cent,  and  27.2  per  cent,  respectively.  Only  ninety-three  heads  of 
the  families  were  reported  as  being  without  occupation.  In  138 
cases  women  were  both  housekeepers  and  family  wage  earners. 

With  the  proportion  of  unskilled  workers  in  this  group,  it  is  not 
surprising  that  family  incomes  were  found  to  be  lower  than  in  such  a 
group  as  that  surveyed  in  Kensington.  The  largest  group  of  families 
had  incomes  of  between  |12.00  and  |15.00  a  week ;  75.3  per  cent  of  the 
856  families  where  income  figures  were  obtained  had  less  than  |20.00 
a  week,  while  94.3  per  cent,  had  less  than  |30.00  a  week.  A  large 
number  of  the  149  families  with  incomes  under  flO.OO  a  week  were 
the  "broken"  families  supported  by  widows  or  young  children,  but 
comparatively  high  incomes  in  other  families  did  not  by  any  means 
act  as  a  safeguard  against  the  need  for  charity. 


120 

Although  Mr.  N.  earned  |25.00  a  week  as  a  "mechanic" 
and  had  only  two  dependents,  a  wife  and  baby  boy,  when  he 
was  ill  with  "throat  trouble"  for  three  weeks  he  was  obliged 
to  secure  medical  attention  through  a  dispensary  and  to  seek 
aid  from  his  relatives  and  a  relief  society. 
We  have,  then,  a  majority  of  cases  in  which  the  family  group  was 
normal,  and  the  main  handicap  was  sickness.    The  families  were  not 
particularly  large  but  the  children  were  generally  young,  and  the 
number  of  wage-earners  per  family,  rather  small. 
♦    There  were  2,682  cases  of  illness  reported  in  these  families.     Na- 
turally enough,  more  often  than  in  a  sickness  survey  among  employees 
in  general,  like  the  one  in  Kensington,  the  illness  reported  was  that 
cof  the  principal  wage-earner,  for  in  such  cases  wage-loss  is  added  to 
the  expense  of  sickness.  ,  Such  illness  was  reported  1,104  times,  or  in 
41  per  cent,  of  the  total  number  of  cases.    Illness  of  the  housewife,  an 
.almost  equally  important  member  of  the  household,  was  reported  761 
times. 

Yet  there  were  cases  in  which  the  illness  of  dependents  alone, 
reported  in  810  cases,  proved  a  severe  strain  on  the  family  resources. 

Mrs.  O.  supported  her  aged  mother  and  three  small  children 
by  work  in  a  hosiery  mill.  The  family  came  to  the  attention 
of  a  relief  society  because  of  the  illness  of  the  grand-mother. 
She  had  been  treated  by  a  private  doctor,  and  the  bills  result- 
ing left  the  family  without  sufficient  food. 

The  two  kinds  of  illnesses  found  in  especially  large  numbers  were 
tuberculosis  and  childbirth.  Four  hundred  and  eighty-eight  cases 
of  tuberculosis  were  noted,  and  247  cases  of  disability  from  pregnancy 
or  child-birth.  These  two  diseases  accounted  respectively  for  18 
and  10  per  cent,  of  all  the  illnesses  recorded. 

It  was  tuberculosis,   the  ^captain  of  the  men  of  death," 
which  incapacitated  Mr.  M.  for  work  for  three  months,  and 
made  it  necessary  for  him  to  obtain  help  from  a  relief  society. 
^  When  he  was  able  to  work  he  was  a  laborer  earning  |15.00  a 

week.  Besides  his  wife,  his  family  was  made  up  of  a  girl  of 
five  and  a  boy  of  two.  A  state  tuberculosis  sanitarium  ad- 
mitted Mr.  M.  for  treatment.  Mrs.  M.  took  in  lodgers  to  cover 
the  rent,  but  was  unable  to  keep  up  because  of  her  expected 
confinement.  A  doctor  gave  free  medical  care,  relatives 
helped  and  material  relief  was  given  by  the  charitable  society. 
Mr.  K.,  a  laborer  whose  pay  averaged  |18.00  a  week,  had  a 
wife  and  a  little  boy  twenty-two  months  old.  He  was  stricken 
with  tuberculosis,  was  sick  and  away  from  work  for  three 
months,  at  the  end  of  which  time  he  had  recovered  sufficiently 
to  be  able  to  go  back  to  work.  His  wife  was  pregnant,  and  a 
relief  society  was  the  main  support  of  the  family  during  his 
illness.  The  Society  was  obliged  to  secure  dispensary  and 
hospital  care  for  him,  prenatal  care  for  his  wife  through  a 
dispensary,  and  a  visiting  nurse  for  her  at  the  time  of  her 
confinement. 


121 

Certain  of  the  cases  pointed  clearly  to  defects  in  community  action 
for  health  or  civic  protection,  for  which  individuals  and  the  funds 
of  private  charity  paid  the  price. 

Mr.  Y.,  a  laborer  in  the  early  thirties  earning  |16.00  a  week, 
was  stricken  with  typhoid,  which  more  than  almost  any  other 
disease,  indicates  a  weak  link  in  the  chain  of  public  health 
measures.    A  wife  and  five  children,  the  oldest  ten,  the  young- 
est two,  were  dependent  on  Mr.  Y.     He  was  sick  nearly  ten 
weeks,  receiving  free  care  in  a  hospital  and  later  dispensary 
treatment.     His  wife  was  at  first  aided  by  friends,  but  was 
later  obliged  to  leave  her  young  family  and  go  out  to  work,  and 
also  to  obtain  charitable  help. 
Other  cases  were  significant  of  the  fact  that  the  lack  of  adequate 
metliods  of  dealing  with  illness  may  cause  not  only  hardship  to  indi- 
viduals, but  may  endanger  the  health  of  the  general  public,  as  when 
w  age  earners  continue  at  Avork  with  a  disease  in  an  acute  communi- 
cable  stage. 

Outside  Philadelphia  data  on  the  full  duration  of  the  illness  was 
obtained  in  386  cases.  Of  these  43  per  cent,  had  lasted  more  than 
six  months,  and  31  per  cent,  more  than  a  year.  The  largest  single 
group  of  illness  lasting  less  than  a  year  were  those  of  between  one 
and  three  months  duration.  Considering  the  illnesses  of  the  wag^ 
earners  alone  in  the  total  group  of  families,  32  per  cent,  lasted  more 
than  six  months,  and  19  per  cent,  more  than  one  year.  Twenty-eight 
per  cent,  of  the  ill  wage  earners  were  ill  between  one  and  three 
months. 

A  considerable  tendency  was  noticeable  for  the  time  out  of  work 
to  be  shorter  than  the  period  of  illness.  For  instance,  although  107 
wage-earners  had  illnesses  lasting  over  a  year,  but  fifty-four  were  out 
of  work  for  this  period ;  while  seventy-eight  were  ill  over  six  months, 
but  forty-nine  were  away  from  work  an  equal  period  of  time. 

METHODS  OF  FAMILY  FINANCE  DURING  ILLNESS. 

The  strain  and  stress  through  which  these  families  passed  is  best 
shown  by  considering  the  ways  in  which  they  maintained  themselves 
during  illness,  and  the  methods  used  were  secured  for  the  Philadel- 
phia families. 

In  one  hundred  and  sixty-three  cases,  the  present  or  future  re- 
s*50iirces  of  the  family  were  drawn  on  in  the  shape  of  savings^  credit, 
or  insurance.  Savings  were  used  in  forty-five  families,  but  usually 
as  the  illness  continued,  in  spite  of  cutting  expenditures  to  the  lowest 
point,  they  were  exhausted  and  other  aid  became  necessary.  In- 
surance although  it  was  carried  in  101  families  was  only  paid  in 
sixty-nine  cases ;  five  cases  of  accidents,  and  sixty -four  of  sickness. 

In  forty-nine  cases,  the  families  borrowed  money,  obtained  credit  at 
the  store,  pawned  their  furniture,  or  ran  into  debt  and  were  left  with 
heavy  bills  at  the  end  of  the  illness. 


122 

Mr.  P's  illness  was  rheumatism,  from  which  he  was  ill  seven 
weeks.  He  was  a  laborer  employed  at  a  wage  of  about  |12.50 
a  week,  and  his  family  "consisted  of  a  wife  and  a  baby  girl. 
While  he  was  at  the  hospital,  they  lived  on  a  little  money  he 
had  saved.  Later  they  borrowed  |30.00  or  ^^40.00  from 
friends  and  received  some  help  from  a  relief  society.  They 
owed  two  months'  rent  when  Mr.  P.  returned  to  work.  But 
even  then  he  was  able  to  work  only  three  or  four  days  a  week, 
both  because  of  his  own  health  and  because  his  wife  then  fell 
sick  and  was  not  able  to  take  care  of  the  baby. 

Mr.  B.  was  a  shoemaker,  who  leceived  little  more  than 
$10.00  a  week  to  support  his  wife  and  six  little  children,  the 
oldest  but  nine  years  old.  He  was  ill  with  an  acute  sickness 
for  four  months,  but  out  of  work  for  only  two  weeks.  To  meet 
the  expenses  of  his  illness,  the  family  "pawned  almost  every- 
thing they  owned,"  and  a  relief  society  secured  hospital  care 
for  Mr.  B,  and  gave  help  to  tide  them  over. 

Not  his  own  illness,  but  an  attack  of  diphtheria  suffered  by 
his  youngest  child,  kept  Mr.  I.  quarantined  and  stopped  his 
wages  for  nearly  six  weeks.  He  was  an  iron  moulder,  earning 
115.00  a  week  or  more,  with  a  wife  and  two  little  girls  of  five 
and  nine  respectively.  After  the  family  had  used  up  their 
small  savings  they  borrowed  money  and  were  left  at  the  end 
of  the  child's  sickness  with  a  doctor's  bill  of  flOO.OO  in  addi- 
tion. 

As  has  been  previously  stated  only  one  case  was  found  in  which 
the  wage  of  an  employee  was  continued  during  the  whole  of  his  illness, 
and  one  in  which  it  was  paid  during  part  of  the  period  of  disability. 
In  thirty-three  other  cases,  however,  the  employer  gave  some  help 
as  a  matter  of  charity.  A  number  of  cases  of  sickness  were  noted 
in  which,  though  working  conditions  seemed  to  be  the  direct  cause 
of  the  illnesses,  the  employer  gave  little  or  no  help. 

In  seventy-six  instances  of  the  illness  of  the  head  of  the  family, 
the  mother  was  obliged  to  go  out  to  work.  The  situation  where  the 
mother  was  unable  to  work  because  of  an  expected  child  has  already 
been  discussed.  It  is  equally  unfortunate  from  a  social  point  of 
view  when  the  mother  of  young  children  is  obliged  to  leave  them 
without  proper  care  and  seek  outside  employment. 

Mr.  J.,  a  laborer  earning  |15.00  a  week,  was  injured  in  an 
accident,  suffering  contusions  of  the  hips  and  thighs.  As  the 
accident  was  not  in  the  course  of  employment,  it  did  not  fall 
within  the  scope  of  the  compensation  law.  Medical  care 
through  a  dispensary  was  provided  by  the  relief  society.  Mr. 
J.  was  away  from  work  three  months.  During  this  time,  the 
family  obtained  help  from  friends,  and  from  a  relief  society, 
and  Mrs.  J.  went  to  work  to  help  support  the  family.  She  had 
three  little  children,  the  oldest  four  and  the  youngest  one, 
and  while  she  was  at  work  the  baby  had  convulsions  and  had 
to  be  taken  to  a  hospital. 


123 

There  were  236  cases  in  which  other  wage-earners  continued  work 
(luring  illness  of  the  head  of  the  family.  A  case  where  the  children's 
earnings  proved  insufficient  follows: — 

All  three  of  the  C.'s  contributed  a  share  to  the  support  of 
the  little  family.    Mrs.  C.  and  the  fifteen-year  old  earned  |8.00 
and  |6.00  respectively  in  the  mill  and  the  fourteen-year  old 
made  |4.00  outside  school  hours.    When  Mrs.  C.  was  disabled 
by  a  broken  finger  for  over  six  weeks,  the  wages  of  the  children 
became  the  main  support  of  the  family,  and  their  standard  of 
living  was  lowered  in  consequence.     The  income  was  so  in- 
adequate that  the  Society  was  called  upon  to  help  with  the 
rent  and  the  other  expenses. 
Assistance  from  relatives  was  secured    for    177    families,    from 
friends  for  ninety-nine,  from  the  church  for  114.     The  proverbial 
generosity  "of  the  poor  to  the  poor"  was  revealed  in  the  aid  given 
by  those  who  had  barely  enough  for  themselves  and  in  the  collections 
so  often  taken  up  among  workers  in  the  same  shop. 

Mr.  F.  a  boiler-maker  earning  |15.00  a  week,  was  ill  for 
eight  weeks  with  typhoid  fever,  which  is,  par  excellence,  the 
socially  preventable  disease.  He  had  a  private  doctor  and  went 
to  a  hospital.  He  had  some  money  saved  and  friends  gave 
money  toward  the  food  and  rent  for  his  wife  and  little  boy. 
A  collection  was  also  taken  up  among  his  fellow- workers. 

Mr.  B.  was  a  brick-layer,  whose  wages  averaged  |15.00  a 
week.     He  had  a  wife  and  five  children,  whose  ages  ranged 
from  fifteen  years  to  twenty  months.     He  contracted  rheum- 
atism from  exposure  while  at  worli,  but  received  no  aid  from 
his  employer.     The  main  support  of  the  family  during  this 
time  came  from  a  fraternal  organization  composed  of  persons 
of  the  same  nationality  as  the  B.'s. 
Though  benefits  under  Pennsylvania's  compensation  law  are  lower 
than  in  many  states,  one  can  but  contrast  its  systematic  provision 
with  the  suffering  under  individualistic  methods  revealed  by  the  sick- 
ness cases. 

Mr.  P.'s  foot  was  crushed  while  at  work,  which  disabled  him 
for  six  weeks.    He  was  a  laborer  with  a  wife  and  one  child; 
he  received  a  weekly  wage  of  |13.00.    Not  understanding  that 
he  would  receive  benefits  under  the  workmen's  compensation 
law,  he  appealed  to  a  charitable  agency  for  help,  but  on  ac- 
count of  the  benefits  to  which  the  law  entitled  him,  it  was  not 
necessary  to  give  financial  relief.     The  requirements  of  the 
law,  moreover,  insured  him  free    treatment    by    the   factory 
doctor. 
This  group  of  families  brought  to  dependency  by  manifold ,  causes, 
but  chiefly  because  of  a  problem  of  illness,  is  not  as  a  whole,  very 
different  from  any  group  of  ordinary  wage  earners'  families.     It  is 
the  group  between  the  self-supporting  and  the  totally  dependent  alms- 
house family;  the  group  which  had  not  been  able  to  meet  alone  the 
emergency,  which  has  touched  it.    The  "down  and  out  pauper's  fam- 
ily" is  hard  to  find.     Such  families  figure  largely  in  our  ideas  and 


124 

conversations  about  "dependency,"  but  even  in  the  almshouses  where 
one  might  perhaps  expect  to  find  them,  they  are  relatively  few.  The 
Old  Age  Pensions'  Commission  has  made  an  intensive  study  of  the 
inmates  of  our  almshouses.  (  Their  conclusions  confirm  ours — the 
great  majority  of  the  dependent  families  to-day  are  simply  those 
normal  families  who  have  not  been  able  to  weather  the  rising  cost 
of  living  and  increase  their  savings,  and  so,  for  a  combination  of 
reasons,  have  been  resourceless  when  illness  or  the  disability  of  old 
age  dropped  upon  them.  The  Board  of  Public  Charities  states  that 
"Persons  in  receipt  of  out-door  relief  for  the  most  part  are  the  de- 
serving poor,  or  those  who  became  destitute  through  old  age  or 
misfortune."  There  may  always  be  a  few  individuals  who  will  be 
chronic  paupers,  but  dependency,  as  it  is  known  to-day,  can  be  in 
large  measure  eventually  abolished.  It  is  a  social  disease  which 
is  nine-tenths  preventable;  it  is  caused  by  maladjustments  which 
should  rightly  be  the  concern  of  the  new  social  order;  disease  is 
foremost  among  these  causes.  How,  then,  can  we  prevent  the  disease 
wherever  possible  and  adequately  meet  the  losses  from  that  portion 
which  cannot  be  prevented? 

Sidney  and  Beatrice  Webb  have  very  clearly  summed  up  the  haz- 
ards which  are  constantly  at  work,  undermining  independence,  and 
recruiting  new  soldiers  for  the  army  of  the  destitute.    They  say: 

"As  a  matter  of  fact,  we  find  five  well-trodden  paths  along  one  or 
the  other  of  which  the  vast  majority — we  might  almost  say  all — of 
the  three  or  four  millions  have  gone  down  into  the  morass  of  destitu- 
tion. At  least  one-third  of  them  are  sick  or  prematurely  broken 
down  in  strength,  and  would  not  be  destitute  but  for  their  sickness 
or  infirmity.  Then  we  have  the  army  of  widows  with  young  children 
on  their  hands,  who  have  been  suddenly  plunged  into  destitution  by 
the  premature  death  of  the  breadwinner.  Of  the  total,  indeed,  one- 
third  are  infants  and  children,  who  are  destitute  not  on  account  of 
any  characteristic  of  their  own,  but  merely  because  their  parents 
are  dead,  or  for  one  reason  or  other  unable  or  unwilling  to  fulfill 
their  parental  obligations.  A  large  contingent  have  fallen  into  desti- 
tution merely  as  the  result  of  the  infirmities  of  old  age;  whilst  an- 
other large  contingent  are  in  the  same  condition  plainly  because  of 
their  inbecility,  lunacy,  or  congenital  feeblemindedness.  Finally,  we 
have  to  recognize  the  able-bodied  person  whose  destitution  comes 
obviously  from  his  prolonged  inability— ^it  may  be  incapacity  or  un- 
willingness—  to  find  sufficient  employment  at  a  sufficient  rate  to  pay 
to  provide  him  and  his  dependents  with  the  necessaries  of  life.  All 
these  roads  run  in  and  out  of  each  other,  creating  what  we  may  ac- 
curately describe  as  a  vicious  circle  round  about  the  morass  of 
destitution — parents  are  led  more  and  more  to  neglect  their  chil- 
dren's needs  if  they  have  neither  work  nor  wages ;  it  is  the  neglected 


125 

child  which  becomes  the  'unemployable'  man ;  the  quite  unnecessary, 
preventable  sickness  to  which  the  wage-earners  are  now  exposed 
withdraws  even  the  skilled  industrious  worker  from  his  job,  or  de- 
prives the  wife  and  children  of  their  breadwinner;  whilst  mentall 
defectiveness  complicates  the  problem  by  a  subtle  deterioration  of 
the  population  as  a  whole.  And  the  four  millions  in  the  morass  are 
not  permanently  the  same  individuals.  Some,  let  us  hope,  escape  and 
rise,  to  reach  again  the  firm  ground  of  adequate  self-support.  Many 
— possibly  four  or  five  per  cent. — die  in  the  course  of  a  year.  Yet  the 
total  remains  at  pretty  nearly  the  same  figure.  It  is  plain,  therefore, 
"that  there  is  a  constant  recruitment.  Every  year  sees  two  or  three 
hundred  thousand  separate  individuals — perhaps  more — pressed  down 
into  the  morass  of  destitution,  along  one  or  other  of  these  roads,  for 
the  first  time.    This,  it  is  clear,  is  what  we  have  to  prevent."^ 

It  is  to  find  methods  of  preventing  this  constant  recruitment  that 
is  our  problem.  Poverty  cannot  easily  be  cured,  but  can  rapidly 
be  prevented,  once  the  supply  of  these  new  recruits  is  cut  off.  Since 
sickness  is  more  than  any  other  single  thing  a  forerunner  of  poverty,, 
how  then  can  we  prevent  sickness,  and  justly  distribute  the  sicknessi 
burden  ? 

No  scheme  of  health  insurance  can  be  expected  to  cure  existing 
poverty.  Health  insurance  is  not  a  "cure-all"  for  dependency  which 
has  been  ■  alread}^  created.  Its  purpose  is  to  prevent  employees  from 
becoming  dependent;  to  cut  off  a  large  proportion  of  those  who 
constantly  fall  into  the  dependent  groi^.  Mr.  McFadden,  speaking 
before  the  National  Fraternal  Congress  of  America  said,  "Pauperism 
has  been  reduced  by  life  insurance  33  per  cent.,  and  saves,  through 
its  forms,  the  nation  in  its  effort  to  maintain  the  poor,  about  $30,- 
000,000  a  year."2 

In  a  special  study  made  for  the  Commission  of  110  families  now 
under  the  care  of  the  Mother's  Assistance  Fund  in  Lancaster  and 
Lackawanna  Counties,  102  were  found  to  have  been  self-supporting 
before  the  father  was  taken  ill. 

Of  1,200  families  of  dependent  widows  with  children  studied  in 
1916  by  this  same  organization,  it  was  found  that  before  the  illness 
which  caused  the  death  of  the  father,  947,  or  79  per  cent.,  of  the 
families  had  been  wholly  self-supporting.  Only  253,  or  21  per  cent., 
were  in  some  way  dependent,  and  but  15  per  cent,  were  in  receipt  of 
Tv^hat  w^as  termed  "charity."  During  the  illness  of  the  father,  the 
number  in  some  way  dependent  upon  outside  resources  increased  to 
35  per  cent.,  and  after  the  father's  death  it  more  than  doubled,  placing 
78  per  cent,  of  the  families  in  a  group  where  self-support  was  im- 
possible.   Thus  at  the  beginning  of  the  illness  almost  four-fifths  were 

(')  Sidney  and   Beatrice   Webb,    The  Prevention   of  Destitution,    pages   6-8. 

(-)F.  T,  McFa<Ulen.  Proceedings  >^atiopa^  Fraternal  Copgress  of  America,  1917,  page  106. 


126 

independent;  after  the  death  of  the  father  almost  four-fifths  were 
forced  into  the  dependent  group. 

In  the  report  oi  the  Mother's  Assistance  Fund/  it  is  stated  that 
the  two  great  causes  of  dependency  in  the  families  under  their  care 
are:  (1)  the  untimely  deaths  of  the  fathers,  due  in  large  part  to 
preventable  accident  and  disease,  and  (2)  the  father's  inability  to 
safeguard  his  family  against  the  death  hazard  on  account  of  low 
wages,  and  the  lack  of  provisions  by  the  state  of  any  form  of  social 
insurance.  / 

VOn  the  whole  conditions  in  Pennsylvania  correspond  only  too  well 
the  description  of  Warren  H.  Pillsbury  of  the  California  Indus- 
trial Accident  Commission: — 

"The  present  method  of  handling  illness  of  wage-earners  is  as  fol- 
lows: The  workman  becoming  ill,  struggles  to  remain  at  work  as 
long  as  possible  to  avoid  loss  of  wages,  and  refuses  to  go  to  a  physi- 
cian until  the  last  moment  because  of  fear  of  expense,  thus  prevent- 
ing treatment  at  the  time  it  is  most  effective,  the  early  stages  of 
the  illness.  When  finally  obliged  to  leave  work,  the  income  of  him- 
self and  his  family  is  ended.  His  savings  will  seldom  last  for  more 
than  a  week  or  two  of  idleness.  He  then  becomes  a  charge  upon 
relatives,  friends,  and  public  charity.  Worry  over  his  financial  con- 
dition prolongs  his  illness.  Inability  to  procure  necessary  medical 
and  surgical  appliances  or  to  take  proper  rest  or  sanitorium  treat- 
ment delays  recovery.  The  children  are  taken  from  school  prema- 
turely and  put  to  work  without  adequate  preparation  or  allowed  to 
go  upon  the  streets.  Eventually  he  may  go  to  the  county  hospital 
for  a  long  period  of  time,  and  his  wife  will  be  taken  care  of  by  the 
Associated  Charities,  or  will  undertake  work  beyond  her  strength 
and  become  ill.  The  employer  has  to  break  a  new  man  into  the  work. 
The  community,  friends  or  relatives  have  to  support  the  family,  and 
the  man  is  inefficiently  and  haphazardly  taken  care  of  because  of 
lack  of  organized  social  endeavor  to  meet  the  problem  presented.' 

(MReport  of  the  Mother's  Assistant  Fund,    1918,   page  38 

(2) Transactions  of  the  Commonwealth  Club  of  California,  June,  1917,  page  173. 


>?2 


127 


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Part  II. — Section  II. — Table  II. — Average  Annual  Wage. 
Manufacturing  Groups  1914.  (') 


Principal 


Name  of  Industry. 


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1 

X3 

a 

1 

es 

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Horticultural   and    floricultural   products, 

Engineering-  and  laboratory  service,  

Building  trades,   

Chemicals  and  allied  products,   

(Jlay,  glass  and  stone  products,  

Clothing  manufactures,  

Food  and  kindred  products,   

Leather  and  rubber  goods,  

Liquors  and  beverages,  

Lumber  and   its  remanufacture,   f. 

Paper  and  paper  products,  1. 

Printing  trades,   

Textiles,  ^- 

Miscellaneous  products, 

Laundries, 

Metals  and  metal  products,  

Mines  and  quarries,  

Tobacco  and  its  products,  

Total,   

20,571  establishments. 


$602 

$425 

$157 

$100 

323 
621 

797 
625 

540 
448 
362 
338 

50 
141 
137 
237 

lOO 
198 
193 

688 
712 

338 

303 

211 

222 

178 
193 

679 

277 

247 

228 

1,002 

166 

157 

20O 

627 

336 

206 

155 

716 

320 

213 

191 

865 

389 

178 

186 

610 

332 

212 

189 

719 

337 

258 

246 

736 

341 

206 

215 

776 

358 

257 

233 

469 

378 

374 

286 

512 

311 

205 

183 

$720 

$335 

$224 

$191 

$936 
1,343 
1,252 
1,330 
1,336 
867 
1,086 
1,397 
1,693 
1,176 
1,383 
1,042 
1,282 
1,409 
865 
1.266 
1,102 
1,089 


$1,297 


(1)  Compiled  from  Production  Report  of  the  Department  of  Labor  and  Industry  for  1914,  pp. 
90-91. 


131 


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132 

Part  II. — Section  II. — Table  IV. — Comparative  Wages— Surveys. 


Family  Income 
per   Week. 


Kensinffton 
Survey. 


Visiting  Nurse 
Study. 


Sickness  and 
Dependency. 


Working   Women's 
Records(i). 


Over  $20.  _. 
$20-$25.     .__, 

$25-$ao.    

Over  $30.  _. 

Total, 


143 
114 

80 

?n 

23.4 
18.8 
13.3 
44.5 

147 

127 

79 

85 

33.5 
28.9 
18.2 
19.4 

644 

112 

51 

49 

75.3 
13.1 
5.9 
5.7 

425 

28 

9 

92.1 

6.0 

(«)1.9 

608 

lOO.O 

438 

100.0 

856 

100.0 

462 

100.0 

(i)Based  on  wages  of  Individual  Women,  not  families. 
(2) "$25  and  over." 


Part  II. —  Section  II. — Table  V. — Per  Cent,  of  Increase  in  Retail  Prices  in  De- 
cember, 1915,  1916  and  1917,  and  August,  1918,  above  the  prices  in  December, 
1914.(1) 

Philadelphia  District,  White  Families. 


Items  of  Expenditure. 

Per  cent,  of  increase  in  retail  prices 
in  December.   1915,   1916,   and  1917, 
and    in    August,    1918,    above    the 
prices  in  December,   1914. 

December 
19]  5. 

December  December 
1916.          1917. 

1 

August 
1918. 

Clothing: 

Male - 

3.30 
3.94 

16.15 
15.90 

54.11 
49.12 

109.36 

Female                             .                                        

106.73 

Total,        -          — 

3.60 

16.03 

51.33 

108.12 

Furniture  and  furnishings,  - 

6.94 

.34 

(2). 29 

(2). 81 

.      1.19 

19.87 
18.92 
(2). 72 
5.37 
14.65 

49.84 
54.41 
2.60 
21.54 
43.81 

105.76 

Food - - 

68.09 

Housing,                                                              - 

9.69 

Fuel  and  light       

31.65 

miscellaneous                                                    --    

67.17 

All  items,  - 

1.19 

14.65 

43.81 

67.17 

(1)  Bureau  of  Labor  Statistics  Monthly  Review,  October,  1918. 

(2)  Decrease. 


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135 


Part  Il.-^Section  II.— Table  VI— B.— Dental  Fee  Schedule.* i 


By    the    hour, 
Amalgam  filling 

Gold,    

Cement,    

Treatments.   — 
Crowns 


Plates,  

Bridge  work,  

Gold  plates  (per  tooth),  __ 

Removing  pulp  and  filling  canals 


&-  12 

50—200 

3—  10 


*I>r.  Alexander  H. 
(1)  "Approximate." 


Reynolds,  Secretary  of  State  Board  of  Dental  Examiners. 


Part  II. — Section  II. — Table  VI — C. — Nurses'  Fee  Schedules. 


Source  of 
Information. 


Female 

Male 

Contagious 

Nufses. 

Nurses. 

•and 

Ordinary 

Ordinary 

Nervous 

Oases. 

Cases. 

Diseases. 

M 

^ 

M 

>. 

>>             ?, 

>, 

s 

<^ 

^ 

s      & 

s 

s 

O 


York       Hospital, 
York,   

$5~ 

$25 
$32 
$25 
$28 

$25- 
$30 

" 

$25 
per  week 

$32 
per  week 

$28 
per  week 

$30 
per  week 

Do  not 
take 

Do  not 
take 

$28 
per  week 

Robert         Packer 
Hospital,   Sayre, 

State       Hospital, 

» 
$5 

« 

$35 

$35 

$25- 
$30 

$37 
$30 
$35 

$30- 
$35 

$5 

$5 

Mercy      Hospital, 
Pittsburgh,  ^ 

$4 

Pennsylvania  Hos- 
pital.    Philadel- 
phia.        - 

*None  available. 


TABLE  VI— D.— Hospital  Fees. 


• 

4H 

2 

Include 

o 

08 

g 

PO 

Name  of  Hospital. 

i 

2 

w 

°3 

2 

> 

1 

00 

U 

■3.5 

•-a 

IS 

CO 

53 

state  Hospital,  Scran- 
ton, 

$2  per  day 

$3.50-4.50  per 
day 

Yes 

Ordinary 

Yes 

$5 

Robert    Packer    Hos- 
pital,   Sayre 

$2  per  day 
$14  per  week 

$21-42  per  week 

Yes 

Yes 

Yes 

$5  ward 
$10  private  room 

York  Hospital,   York, 

$1.50  per  day 
$10.50  per  week 

$3-5  per  day 

Yes 

Yes 

Yes 

$5  room 

$5  anaesthetic 

Mercy  Hospital,  Pitts 
burgh 

$10-12  per  week 

$20-75  per  week 

No 

Yes 

Yes 

$5-10 

Pennsylvania    Hospi- 
tal. Philadelphia 

$'^  per  day 

$3-6  per  day 

No 

Yes 

No 

$5 

136 


Part  II. — Section  II. — Table  VII. — Expenditures  for  Sickness  Care. 


.*• 

©ost  of  Living  Studies,  United  States 

Cost  of  Living  Study 

.  Phila- 

Bureau  of  Labor  Statistics. 

delphia  Bureau  of  Munici- 

pal Research. 

Philadelphia. 

Chester 

. 

Dollars. 

•a 

H 

•3 

. 

„. 

^ 

1 

1 

S 

• 

s 

1 

1 

1 

If 

None.    

7 
16 
25 
49 
60 
26 
4 
3 
1 

89 
42 
23 
23 
11 
3 

4 
8 
22 
45 
39 
42 
6 
4 
1 

10 

7 
9 

11 

1 
1 

14 
15 
1 
6 
3 
1 

7 
4 
10 
13 
4 
1 

4 
52 

28 

•?? 

17 
3 

1 
1 

127 
59 
22 
37 
9 
5 

__ 

2 
35 

25 
74 
85 
SO 
6 
1 

76 

Less  than  6, 

6-  10,     

143 

22 

11-  25 

11 

26-  50      

8 

51-100.     

101-150      

151-200 

201-225,        —    

212  60, 

1 

252.00, 

1 

1 

312.00,     

1 



-- 

__ 



418.00.       

450  00 

463.00      

1 

Total.     

192 

192 

192 

40 

40 

40 

260 

260 

260 

260 

(1)  Included  in  "medical.' 


Part  II.—  Section  II.— Table  VIII.— Cost  of  State  Hospitals  for  Miners.i 


Year  End- 
ing May 
31,  1912. 

Year  Ebd- 
ing  May 
31,  1913. 

Year  End- 
ing May 
31,  1914. 

Year  End- 
ing May 
31,  1915. 

Year  End- 
ing May 
31,  1916. 

Number  of  hospitals,   

Receipts    from    patients    and 
friends  of  patients,   

8 

$27,735.92 

254,199.71 

287,990.85 

646 

8,481 

7,559 

380 

«7,303 

10 

$36,364.99 

286,774.87 

372,525.41 

791 

11, MS 

9,688 

256 

227,895 

10 

$46,912.10 

337,662.29 

429,781.64 

789 

12,143 

10,552 

640 

262,371 

10 

$54,071.86 

349,256.63 

433,243.92 

855 

14,567 

12,150 

1,176 

261,688 

10 

$64,553.01 
369,456.25 

Expenditui-es      

439.428.92 

Total  number  of  beds,  

Total  number  patients,  

Number   free  in-patients,    

Nnmhwir   nartlv    frpp 

821 
14.451 
12,617 

TVifnl    nnmhAr    rlavs 

280.785 

Total  cost  free  days.  — 

$266,298.19 

$335,362.45 

$381,165.38 

$373,914.80 

$366,955.60 

(1)  Taken  from  Reports  of  State  Board  of  Public  Charities. 


137 


Part    II.— Section    II.— Table    IX.— Statistics    of    Hospitals    Reporting    to    State 

Board  of  Oharities.i 


Number  of  hospitals  covered, 
Total    received     for    mainte- 
nance,     

From  patients  and  friends  of 

patients,    

From  the  State,  

From  donations,   

Total   expenses,    

Number  hospitals  having  de- 
ficit.     

Total  deficit,   

Total  number  of  beds, 

Total      number      in-patients 

treated,    

Number  treated   free,   

Numbers  treated  partly  free,— 
Total    number    free    hospital 

days,    

Number    of    dispensary    pa- 
tients,,     

Received  from  dispensary  pa- 
tients,    

Fixed  indebtedness,    


Year 

Ending  May 

31,  1912. 


$6,555,562  52 

$2,203,891  71 

$1,977,400  73 

$370,764  08 

$8,586,819  35 

103 

$665,505  97 
15,244 

181,954 
97,723 
34,838 

1,918,000 


$9,471  71 
$4,372,220  90 


Year 

Ending  May 

31,  1913. 


tl63 
$7,204,611  49 

$2,727,091  20 

$2,172,727  03 

$414,499  84 

$7,195,031  66 

68 

$203,456  85 

15,547 

204,310 

103,895 

42,900 

2,012,572 
797.958 

$67,015  74 
$4,620,754  34 


Year 

Ending  May 

31,  1914. 


n62 

$7,186,453  37 

$2,900,744  11 

$2,304,890  14 

$270,048  60 

$7,414,594  90 

85 
$435,814  51 


206,116 

103,987 

42,713 

2,136,996 
Sr7,S72 

$87,439  71 
$4,522,304  51 


Year 

Ending  May 

31,  1916. 


U69 
$6,964,112  57 

$2,929,314  58 

$2,362,308  60 

$118,519  01 

$7,418,244  88 

130 

$622,516  60 
16,503 

166,428 

116,538 

45,918 

2,128,707 

852,204 

$64,737  34 
$4,482,620  36 


Year 

Ending  May 

31,  1916. 


175 
$7,306,726  42 


$3,268,287  16 
$2,319,688  96 


$7,937,065  10 

102 

$734,486  49 

16,351 

219,834 
127,678 


1.687,34« 
868,171 

$83,727  81 
$4,546,649  62 


Part  II. — Section   II. — Table  X. — Statistics  of  Sanatoria  Reporting  to  State 

Board  of  Charities. 


Number  of  sanitoria  covered, 
Total    received    for    mainte- 
nance,    

From  patients  and  friends  of 

patients,    

From  the   State,   

From  donations, 

Total  expenses,  

Number  sanitoria  having  de- 
ficit.     

Fixed  indebtedness,    

Total  number  of  beds  for  pa- 
tients,    

Total      number      in-patients 

treated,    

Number  treated  free,  

Number  treated   partly   free. 

Total  number  free  days,   

Number    of    dispensary    pa- 
tients,      

Received  from  dispensary  pa- 
tients,     


Year 

Ending  May 

31,  1912. 


$250,255  20 

$99,343  06 

$38,111  90 

$54,805  09 

$222,386  00 


471 

1,637 

479 

831 

57,510 

0,357 
$209  10 


Year 

Ending  May 

31,  1913. 


$275,377  90 

$106,434  06 
$45,120  44 
$74,874  02 

$284,610  53 

3 

$13,000  00 


1,805 

759 

1,908 


14,508 


Year 

Ending  May 

31,  1914. 


$338,880  60 

$90,404  00 

$41,655  60 

$142,225  91 


$27,000  00 


1,093 

431 

92,945 

11,554 

$1,930  43 


Year 

Ending  May 

31,  1915 


12 

$333,449  09 

$98,230  25 
$49,377  39 

$2,077  70 
$363,185  88 

6 

$27,000  00 

498 

1,807 

970. 

800 

125,741 

23,134 
$118  49 


Year 

Ending  May 

31,  1910. 


$235,342  38 

$42,531  34 
$50,500  00 


$263,108  11 

5 

$27,000  00 

481 

1,099 
649 


57,734 
5,273 

$603  30 


(1)  "State  Hospital"  not  included  after  1911. 

♦  Sixteen  of  these  received  no  State  aid. 

t  Seventeen  of  these  received  no  State  aid. 

JNo  information  about  number  not  receiving  State  aid. 


138 


Part   II.- 


-Section   II. — Table   XI. — Certain    Statistics   of   Hospitals   Reporting  ■  to 
State  Board  of  Charities  for  Fiscal  Years  1916  and  1917. 


Item. 


Year  Ending 
May  31,  1916. 


Year  Ending 
May  SI,  1917. 


Total  receipts,  

Total  expenditures,    

Apparent  deficit,  

Number  of  free  in-patients,  

Number  of  pay  patients,  

Number  of  free  days,  

Average  per  capita  of  patients,* 


$7,306,726  42 

7,937,065  10 

630,328  68 

127,678 

92,156 

1,627,346 

*$1  98 


$8,708,846  37 

9,526,061  27 

817,214  90 

154,216 

92,773 

1,580,728 

*$2  2« 


♦Average  not  weighted  by  number  of  beds  per  hospital. 


Part  II.- 


-Section  II. — Table  XII. — Number  of  Cases  of  Out-door  Relief  in  Alms- 
house Districts  as  Reported  to  the  State  Board  of  Charities. 


Cause  of  Destitution. 


Year  End- 
ing Dec. 
31,  1912. 


Year  End- 
ing Dec. 
31,  1913. 


Year  End- 
ing Dec. 
•31,  1914. 


Year  End- 
ing Dec. 
31,  1915. 


Year  End- 
ing Dec. 
31,  191«. 


Old  age  or  permanent  disability. 
Temporary  sickness  or  death,  — 
Want  of  work,  


Desertion    or    absence    of    heads    of 

families,    

Intemperance,  


Insanity,  idiocy  or  feeble-minded. 
Other,   


5,287 

15.88% 

15,414 

46.27% 

5,157 

15.48% 

5,635 

16.91% 

997 

2.99% 

247 

2.47% 


Total, 


33,311 


19.30% 

15,455 

45.90% 

4,689 

13.93% 

5,256 

15.61% 

1,110 

3.30% 

633 

1.96% 


33,672 


7,821 

15.24% 

19,863 

38.71% 

13,289 

25.86% 

7,334 

14.30% 

2,178 

4.25% 

668 

1.30% 

178 

0.34% 


51,311 


6,050 

14.06% 

15,367 

36.70% 

10,766 

25.02% 

7,682 

17.89% 

2,398' 

5.57% 

772 

1.79% 


43,035 


7,531 

20.85% 

17,092 

47.33% 

3,213 

8.90% 

5,877 

16.22% 

1,692 

4.68% 

713 

1.97% 


36,118 

100.00% 


PART  II. 
SECTION  III. 

The  Adequacy  of  Present  Methods  of  Care. 


/ 

( 139  ) 


m 


(140) 


141 


PHYSICIANS  IN  PENNSYLVANIA. 

The  number  of  physicians  in  the  state  at  the  present  time,  because 
of  the  demands  of  the  army  for  medical  service,  is  of  course  in  no  way 
representative  of  normal  conditions. 

According  to  the  report  of  the  Social  Insurance  Committee  of  the 
American  Medical  Association,  however,  there  were  in  1916,  11,502 
legally  qualified  physicians  in  Pennsylvania,^  or  an  average  of  one 
physician  for  each  729  persons.  This  corresponds  fairly  Avell  to  the 
standard  of  one  physician  for  each  700  persons,  considered  adequate 
by  the  Committee,  but  gives  no  idea  of  the  unevenness  of  distribu- 
tion. It  is  interesting  to  find  that  while  Philadelphia,  Pittsburgh, 
and  Scranton  have  one  physician  for  each  431,516,  and  663  persons 
respectively,  Hazelton  and  Shenandoah,  both  important  minftig  com- 
munities, have  848  and  1,031  persons  respectively,  for  each  physician. 
The  contrast  between  urban  and  rural  communities  is  even  more 
marked,  for  in  the  latter  the  number  of  persons  per  physician  is  1,297 
as  compared  with  524  in  cities  of  25,000  and  over.  Among  the  most 
important  reasons  for  this  are  the  economic  conditions  in  the  various 
communities,  which  determine  their  ability  to  offer  fair  or  poor  re- 
muneration for  medical  work. 

HOSPITAL  FACILITIES  IN  PENNSYLVANIA. 
From  the  medical  directory  issued  annually  by  the  American 
Medical  Association,  a  list  furnished  by  the  Modern  Hospital  maga- 
zine, and  the  directory  of  the  Board  of  Public  Charities,  the  number 
of  beds  in  public  hospitals,  special  and  general,  in  each  county  of  the 
state  was  computed  for  the  year  1916.  This  of  course,  is  an  over- 
estimate of  the  facilities  available  to  the  average  employee,  for  it  in- 
cludes a  number  of  beds  in  private  rooms,  which  are  far  beyond  his 
means.  No  data  is  available,  however,  by  which  these  can  be  de- 
ducted. There  were  a  total  of  20,118  beds  in  the  public  general  hos- 
pitals of  the  state  in  1916.  Various  classes  of  public  special  hos- 
pitals including  those  for  epilepsy,  tuberculosis,  contagious  diseases, 
cancer,  maternity,  surgical  work,  children's  diseases,  and  eye  and  ear 
cases  contained  an  additional  6,603  beds,  and  insane  asylums  con- 
tained 11,843.  Exclusive  of  these  asylums  the  total  number  of  beds 
in  public  hospitals  was  26,721,  or  3.4  beds  per  1,000  persons  on  the 
basis  of  the  population  of  the  state  in  1910.  On  the  basis  of  the  esti- 
mated population  in  1916  (8,522,017)  the  number  of  l^eds  per  1,000 
population  is  3.1.  Either  estimate  is  far  below  the  five  beds  per  1,000 
population  which  authorities  tell  us  are  necessary  for  adequate  hos- 
pital accommodation. 

,,  ^i.^  ^t**J^*'*^^  ^.^^''^^"Sr  the  Medical  Profession,  Social  Insurance  Series,  Pamphlet  VII.  American 
Medical  Association. 


142 

Sixteen  of  the  sixty-seven  counties  in  Pennsylvania,  some  of  them 
at  considerable  distances  from  better  supplied  areas,  have  no  hospital 
beds  whatever,  and  nine  other  counties  have  less  than  one  per  1,000 
persons.^ 

A  division  of  the  state  into  sections,  as  shown  by  the  appended 
map,-  illustrates  the  inadequacy  of  existing  hospital  facilities. 

The  nineteen  counties  included  in  Section  I  represent  the  bitumi- 
ious  coal  region  of  Pennsylvania,  and  in  1910  produced  162,010,331 
tons  of  coal,  or  more  than  95  per  cent,  of  the  entire  bituminous  out- 
put of  the  state.  This  district  with  a  population  of  2,636,026  persons 
or  34.38  per  cent,  of  the  total  state  population,  has  8,276  hospital 
beds,  or  an  average  of  3.1  beds  per  1,000  persons.  More  than  two- 
thirds  of  these  beds  are  located  in  Allegheny  County,  which  has  only 
38.6  per  cent,  of  the  poi)ulation  of  the  entire  district,  and  is  not 
readil}^  accessible  to  the  most  remote  and  most  poorly  equipped 
counties.  Exclusive  of  Allegheny  Coimty^  the  average  number  of 
beds  per  1,000  population  for  the  district  is  only  .14-  Because  of 
the  higlily  industrial  character  of  the  population  and  the  health  anfl 
accident  hazards  involved  in  mining,  this  provision  is  shockingly 
inadequate.  Two  counties,  neither  of  which  is  within  easy  reach  of  a 
well-supplied  area,  have  no  beds  at  all,  and  six  have  less  than  one 
bed  per  1,000  persons. 

Section  II,  the  anthracite  coal  district,  comprises  eleven  counties 
with  a  population  of  1,132,035  or  14,76  per  cent,  of  the  total  popula- 
tion of  Pennsylvania.  The  1916  coal  production  of  these  counties  was 
87,680,198  tons,  or  more  than  98  per  cent,  of  the  anthracite  output 
of  the  state.  In  this  whole  section  there  are  only  1,872  beds  or  1.65 
per  1,000  persons,  and  the  distribution  is  still  more  uneven  and  un- 
satisfactory than  in  the  bituminous  district.  Four  of  the  eleven 
counties  have  no  hospital  beds,  and  are  not  accessible  to  adequately 
supplied  districts. 

Section  III,  which  includes  the  northern  and  north  central  coun- 
ties, thirteen  in  all,  has  an  average  if  2.72  beds  per  1,000,  or  1,792 
for  the  population  of  656,698.  The  distribution,  exclusive  of  Erie 
County,  which  has  almost  one-third  the  total  number  of  beds,  is  more 
even  than  in  the  anthracite  and  bituminous  districts,  although  Cam- 
eron and  Forest  Counties  are  entirely  lacking  in  hospital  facilities. 
Forest  lies  next  to  Clarion  County,  one  of  the  two  bituminous  coun- 
ties which  have  no  beds. 

The  twenty -three  remaining  counties  of  the  state  make  up  Section 
IV,  which  has  42.29  per  cent,  of  the  total  state  population.  This 
section,  in  comparison  with  the  other  three,  stands  slightly  higher 
in  the  number  of  beds,  having  12,545  for  the  population  of  3,240,353 
or  3.87  per  1,000.    But,  exclusive  of  Philadelphia  County  with  9,65!) 


(i)See  Table  II   at  end  of  this   section. 
(2)  See  Table  I  at  end  of  this  section. 


143 

beds  or  6.2  per  1,000,  the  average  for  the  district  is  only  .88,  while 
eight  counties  have  no  beds  at  all.  Of  these  eight  counties,  four. 
Union,  Snyder,  Juniata  and  Perry  are  adjacent.  Perry  is  next  to 
Cumberland  with  an  average  of  only  .90  beds  per  1,000  and  south  of 
Cumberland  is  Adams  County,  with  no  beds.  Fulton  with  no  beds 
joins  Franklin  with  only  1.0  per  1,000,  and  Bedford,  one  of  the  bitu- 
minous counties  with  no  hospital  facilities. 

This  concentration  of  existing  hospitals  in  the  two  large  cities  of 
the  state  is  not  surprising,  and  there  is  no  evidence  to  show  that 
these  cities  are  over-supplied  with  hospital  accommodations.  The 
problem  is  not  so  much  one  of  poor  distribution  as  of  inadequate 
supply. 

But  even  if  accommodations  were  adequate,  it  would  not  be  pos- 
sible to  look  with  satisfaction  on  the  hospital  situation  of  the  state. 
When  the  cost  of  ward  heds  is  beyond  the  means  of  probably  half 
the  employees  of  the  state;  ichen  in  a  single  year ^  nearly  2,000 fiOO 
days  of  free  hospital  treatment  are  gix)en  and  almost  000.000  persons 
patronize  charity  dispensaries,  some  change  in  method  is  called  for 
which  will  make  medical  care  at^aAlable  to  the  average  employee  as  a 
matter  of  right,  not  charity. 

MEDICAL  CARE  RECEIVED  BY  EMPLOYEES  AND  THEIR  FAMILIES.i 
The  sickness  surveys  show  a  considerable  number  of  sick  persons 
who  receive  no  medical  attention  at  all,  or  receive  it  too  late  to 
prevent  the  illness  from  becoming  serious.  In  Pittsburg  and  West- 
ern Pennsylvania,  25.4  per  cent,  of  the  illnesses,  including  49.4  per 
cent  of  the  persons  sick  but  able  to  work,  and  24.2  per  cent  of  those 
actually  disabled,  had  no  medical  care.  In  the  Philadelphia  Survey 
21.7  per  cent,  of  the  514  cases  of  illness  were  treated  only  by  patent 
medicines  and  home  remedies.  In  an  additional  16.3  per  cent,  the 
kind  of  treatment  was  "unknown,"  and  it  is  probable  that  the  major- 
ity of  these  received  no  care.  A  physician  had  been  consulted  in  only 
60'  per  cent,  of  the  total  number  of  cases.  Among  the  Kensington 
families,  no  care  at  all  was  received  in  154  cases  and  home  treatment 
or  patent  medicine  only  in  an  additional  144  cases,  making  a  total 
of  14.9  per  cent,  of  the  1,994  illnesses  found  in  the  survey. 

The  use  of  patent  medicines,  which  was  more  fully  discussed  in  the 
section  on  "The  Cost  of  Medical  Care,"  is  a  striking  feature  in  every 
group.  Of  348  girls  in  the  study  of  Working  Women  who  had  ex- 
penditures for  medical  care,  39.9  had  medicine  only.  Although  97.5 
per  cent,  of  the  1,360  cases  of  illness  in  the  Visting  Nurse  Study 
were  said  to  have  had  medical  care,  11.4  per  cent,  of  these  had  had 
only  patent  medicine.  The  nurses  who  made  this  study  were 
impressed  with  the  inadequate  character  of  the  care  generally 
received. 


(i)See  Table  III  at  the  end  of  this  section. 

10 


14:4 

In  cases  where  medical  care  was  reported,  a  private  physician  had 
most  often  been  consulted.  This  was  true  in  86.6  per  cent,  of  the 
treated  illnesses  in  Pittsburgh  and  Western  Pennsylvania,  48.9  per 
cent,  of  those  in  the  Visiting  Nurse  group,  37.1  per  cent,  of  those  in 
Kensington,  and  57.1  per  cent,  of  the  working  women  who  had  expen- 
ditures for  medical  care.  In  all  except  the  Sickness  and  Dependency 
Study,  the  use  of  the  "district  doctor,"  dispensary,  hospital  or  con- 
valescent home  was  infrequent,  tuberculosis,  accidents  and  mental 
diseases  being  the  usual  cause  of  institutional  care.  Nursing  care 
was  reported  in  less  than  10  per  cent,  of  the  cases.  This  figure  was 
highest  in  the  Visiting  Nurse  Society  Study,  where  it  was  recorded 
for  11.1  per  cent,  of  tlie  cases  under  treatment.  About  10  per  cent, 
of  the  nurses  were  described  as  "practical  nurses." 

The  amount  of  free  treatment  cannot  be  accurately  estimated,  but 
there  were  many  instances  in  wkich  the  fact  of  medical  charity  was 
beyond  dispute.  For  instance  in  the  Sickness  and  Dependency 
Study,  the  Poor  Boards'  "district  doctor"  was  called  in  119  times 
and  a  dispensary  was  consulted  421  times.  No  doubt  most  of  the  435 
persons  who  went  to  a  sanitarium  and  seventy-one  who  went  to  a 
convalescent  home  were  also  treated  free  of  charge.^  Within  the 
Visiting  Nurse  group,  37.8  per  cent,  of  the  nursing  care  was  only 
partially  paid  for,  and  an  additional  14.8  per  cent,  was  given  entirely 
free,  while  in  the  324  cases  treated  by  city  doctors,  "practical  nurses," 
dispensaries,  hospitals  and  convalescent  homes,  there  were  certainly 
many  instances  of  medical  charity. 

A  special  study  of  maternity  care  in  Pennsylvania  would  be  highly 
desirable  as  certain  facts  on  this  subject  which  have  been  noted 
indicate  that  mothers  too  frequently  fail  to  receive  proper  attention 
at  this  critical  time.  For  instance  the  Federal  Children's  Bureau,  in 
its  study  of  infant  mortality  in  Johnstown,  states  that  37.9  per  cent, 
of  the  motliers  of  children  'born  in  1911  in  that  city  had  only  a  mid- 
unfe  as  attendant  at  the  births  of  their  babies^  and  2.S  per  cent.-  no 
attendant^  or  neighbors,  relatives  or  friends.  Out  of  1,463  of  the«e 
mothers,  401  took  up  all,  and  626  others  at  least  part,  of  their  house- 
hold duties  in  less  than  fourteen  days  after  confinement.  The  infant 
death-rate  was  considerably  lower  in  the  cases  having  better  atten- 
tion and  the  longer  period  of  rest.^ 

It  is  well  known  that  every  expectant  mother  requires  special  pre- 
natal care  and  instruction  to  safeguard  her  own  life  and  health  and 
that  of  her  child.  Yet  the  Dispensary  Aid  Society  of  Pittsburgh 
reported  that  in  the  district  in  which  they  carried  on  intensive  child 
hygiene  work  during  the  year  ending  April  1,  1916,  only  ten  out  of 
106  mothers  had  had  any  prenatal  care."' 

(')Tn  many  of  the  abovp  rasos  of  course,  more  than  one  kind  of  modioal  rare  was   used. 
(2)Children's  Bureau;   "Infant  Mortality,  Results  of  a  Field  Study  in  Johnstown,   Pa."       Bureau 
Publication  No.  9,  pases  32,   38.  34.  45. 

C)  Dispensary  Aid  Society,  Tuberculosis  League  of  Pittsburgh,     Fir»t  Survey  Report,  page  52. 


145-" 

The  fact  has  been  emphasized  in  connection  with  the  Sickness  and 
Dependency  Study  that  the  crisis  of  childbirth  combined  with  the 
illness  of  the  breadwinner,  frequently  exhausted  family  resources  and 
required  charitable  aid.  One  or  two  cases  were  found  in  which  the 
husband  was  obliged  to  stay  at  home  from  work  and  care  for  his  wife 
because  no  other  help  was  available. 

The  difficulties  of  the  working  mother,  whose  income  stops  just  at 
the  time  she  is  most  in  need  of  it  were  often  illustrated. 

Mr.  P.  was  a  laborer,  but  his  work  was  irregular,  and  his  wife  did 
washing  to  help  support  the  five  children.  Olga,  the  oldest  girl,  was 
of  working  age  but  had  never  been  able  to  work  on  account  of  tuber- 
culosis, and  during  the  time  the  relief  society  was  interested  in  the 
family,  she  went  to  a  state  tuberculosis  sanitarium,  where  she  died. 
The  record  states  that  Mrs.  P.  "worked  nearly  up  to  the  time  of  her 
confinement  and  as  soon  after  as  she  could  stand  on  her  feet."  She 
had  no  prenatal  care. 

MEDICAL  CARE  RECEIVED  BY  MINERS  AND  THEIR  FAMILIES. 

A  special  eft'ort  was  made  by  the  Commission  to  investigate  the 
extent  and  nature  of  sickness  care  received  by  miners  and  their 
families.  Although  conditions  vary  widely,  the  following  facts  are 
generally  true : 

A  great  many  companies,  especially  in  the  bituminous  region,  have 
organized  systems  of  "contract  practice"  under  which  each  employee 
pays  a  definite  monthly  sum,  usually  from  fl.OO  to  $1.50  if  he  is  mar- 
ried, and  from  fifty  to  seventy-five  cents  if  he  is  single.  These  sums 
are  paid  by  the  employers  to  physicians  who  agree  to  care  for  illness 
among  the  miners  and  their  families.  Operations,  maternity  cases 
and  long,  serious  illnesses  are  usually  excluded  from  the  list  of  ail- 
ments to  be  treated,  and  medicines,  appliances,  etc.  are  frequently 
charged  for  in  addition.  Although  this  practice  seems  to  be  proving 
satisfactory  in  some  districts,  it  has  been  abandoned  by  practically 
all  the  anthracite  operators  and  by  two  of  the  largest  companies  in 
the  bituminous  region.  The  objections  to  it  seem  to  be  the  usual 
criticisms  made  of  "contract"  and  "lodge"  practice,  with  the  addi- 
tional complaint  that  in  many  cases  too  few  doctors  are  employed. 
One  company,  for  instance,  had  one  doctor  and  one  nurse  to  care  for 
between  2,000  and  3,000  families  living  in  nine  different  districts 
within  a  radius  of  several  miles.  As  no  records  are  kept  by  the  doc- 
tors practicing  under  this  contract  system,  it  is  almost  impossible  to 
get  any  clear  idea  of  the  extent  of  their  work. 

The  state  maintains  ten  hospitals  for  miners  whose  work  is 
described  in  Part  III,  Section  I  of  this  report.  In  addition,  a  few 
companies,  mostly  in  the  anthracite  district,  maintain  private  hos- 
pitals where  their  employees  and  sometimes  members  of  their 
families,  may  receive  practically  free  treatment.  The  foreign  work- 
ers, as  a  rule,  appreciate  the  advantages  of  hospital  care  more  keenly 


.  146 

than  the  Americans  and  take  advantage  of  the  opportunity  to  secure 
it  to  greater  extent.  In  some  instances,  the  location  of  the  hospitals 
makes  it  practically  impossible  for  members  of  the  family,  or  even  the 
family  physician,  to  visit  the  patient,  in  which  case  hospital  care  is 
less  often  received. 

Employees  of  the  large  number  of  operators  who  do  not  maintain 
the  "contract  system"  depend  upon  lodge  doctors  and  private  prac- 
titioners for  treatment.  In  many  communities  physicians  make  a 
specialty  of  this  kind  of  practice  and  the  care  given  is  very  good, 
especially  among  Hungarian  and  Slavic  families  who  are  noted  for 
their  scrupulousness  about  paying  for  treatment.  In  the  Western 
Pennsylvania  Survey,  the  Metropolitan  Life  Insurance  Company 
found  that  85.4  per  cent,  of  the  bituminous  miners'  illnesses  and  77.4 
per  cent,  of  those  among  anthracite  miners  received  medical  care. 
This  was  attributed  partially  to  the  large  number  of  accident  cases 
included  in  the  survey.     The  report  states: 

"It  must  not  be  inferred  from  the  higher  ratios  of  medical  attend- 
ance shown  for  the  three  occupational  classes  (anthracite  and 
bituminous  miners  and  iron  and  steel  workers)  that  these  special 
groups  are  better  able  financially  to  provide  private  medical  care  for 
themselves."^ 

^^s  a  rule,  maternity  cases  receive  less  frequent  and  poorer  treat- 
ment than  any  others.  Midwives,  frequently  untrained,  are  generally 
employed,  instead  of  physicians.  Nursing  care  is  very  seldom  avail- 
able, and  little  is  being  done  to  encourage  the  improvement  in  sanita- 
tion and  health  knowledge  that  would  do  so  much  to  decrease  the 
amount  of  sickness,  particularly  among  young  children.  Attempts 
have  been  made  by  some  insurance  companies  to  provide  nursing 
service  for  their  industrial  policy-holders,  but  as  yet  this  is  in  no  way 
adequate.  One  company  employed  before  the  war  two  nurses  to  care 
for  about  eight  thousand  policy-holders  living  in  a  district  with  a 
ten-mile  radius. 

The  experience  of  one  bituminous  mining  company  employing  about 
2,000  men  is  interesting.  In  their  "contract  system"  they  have  four 
physicians  and  a  visiting  nurse,  as  well  as  facilities  for  giving 
instructions  in  hygiene,  prenatal  and  inf^t  care.  They  consider 
that  the  cost  of  maintaining  this  care  is  more  than  met  by  the 
improvement  in  the  health  and  efficiency  of^heir  employees.  This 
seems  to  have  been  the  experience  of  the  mining  companies  generally, 
so  far  as  accidents  are  concerned,  for  most  of  them  carry  their  own 
compensation  insurance  and  provide  immediate  and  adequate  care 
for  industrial  accident  cases.  The  health  conditions,  especially 
among  the  families  of  these  miners,  would  seem  to  make  imperative 
some  similar  provision  for  sickness  care. 


(^) Sickness  Survey  of  Prinoipal  Cities  in  Pennsylvania  antl  West  Virginia,   page  37, 


147 

MEDICAL  CARE  IN  ALMSHOUSES. 
Figures  supplied  to  the  Commission  by  the  Board  of  Public 
Charities  give  a  fair  idea  of  facilities  for  medical  care  in  sefenty- 
nine  almshouses  in  the  state.  Thirty-two  of  these  institutions,  or  40 
per  cent.,  contain  no  hospitals  facilities  whatever,  and  there  are 
such  great  differences  between  the  so  called  ^^hospitals"  in  the  others 
that  it  is  impossible  to  consider  many  of  them  adequate.  Over  half 
the  institutions  have  no  hospital  equipment  or  it  is  described  as 
"poor."  Only  twenty-five  have  nurses  in  attendance,  although 
practically  all  have  "matrons"  and  "attendants."  In  fifty-six  cases, 
a  physician  is  said  to  be  in  charge,  but  as  this  is  very  often  known  to 
be  the  County  Doctor  who  can  be  called,  it  is  doubtful  whether  many 
places  have  a  resident  physician.  No  records  are  available  showing 
the  number  of  almshouse  inmates  who  are  ill  during  the  year,  the 
number  of  visits  made  by  the  attending  physicians  or  the  nature  or 
length  of  the  illnesses.  The  fact  that  so  little  is  known  by  the  Board 
of  Public  Charities,  which  has  charge  of  the  seventy-nine  institutions, 
about  the  type  of  medical  care  given,  is  evidence  of  its  casual  and 
inadequate  character. 

EXISTING   HEALTH    INSURANCE   IN    PENNSYLVANIA. 
The  carriers  of  Health  Insurance  at  the  present  time  in  Pennsyl- 
vania may,  be  roughly  classified  as  commercial  insurance  companies, 
trade  umons,  fraternal    orders^    and    estahlishment   funds  covering 
employees  of  individual  estahlish/ments. 

Commercial  Insurance  Companies  Carrying  Health  Insurance. 

In  the  absence  of  any  social  organization  by  the  state,  certain 
commercial  insurance  companies  have  entered  into  competition  with 
Trade  unions,  fraternal  orders,  and  establishment  funds  covering 
sickness  insurance  for  wage  earners.  The  reports  from  these  com- 
panies are  difficult  to  secure  and  do  not  classify  their  policy-holders 
so  that  the  number  of  employees  among  them  can  be  ascertained. 
The  better  paid,  skilled  employees  may  be  able  to  pay  for  a  fair 
amount  of  accident  and  sickness  insurance,  but  the  rates  are  pro- 
hibitive for  the  majority.  It  is  only  because  the  need  for  insurance 
is  so  widely  felt  and  protection  against  sickness  so  necessary,  that 
the  business  of  these  companies  is  growing.  Most  of  them  began 
by  offering  accident  insurance,  but  the  demand  for  sickness  insur- 
ance became  so  great  that  this  Avas  included. 

In  the  latest  report  of  the  Pennsylvania  State  Insurance  Depart- 
ment, 1916,  figures  for  sixteen  Commercial  insurance  companies  are 
given.  These  companies  paid  during  that  year,  4,924  claims  for  acci- 
dents and  illnesses,  amounting  to  |84,725.59.^ 


(i)See  Table  IV  at  end  of  this  section. 


148 

The  larger  part  of  this,  in  all  probability,  went  to  employers  and 
professional  men,  rather  than  to  the  rank  and  file  of  employees. 

To  appreciate  the  slight  extent  to  which  commercial  insurance  com- 
panies have  developed  a  health  insurance  business  among  the 
employees  of  the  state,  a  comparison  may  be  made  between  the 
184,725.58  paid  out  for  4,924  health  insurance  and  accident  claims 
in  1916  by  sixteen  of  these  companies,  with  the  business  done  by  the 
three  principal  companies  doing  an  industrial  life  insurance  business. 
It  will  be  found  that  the  great  majority  of  employees  are  insured 
in  this  way  fur  sums  of  from  flOO.OO  to  |500.00,  the  premiums  for 
which  are  paid  weekly  to  agents  making  door-to  door  collections. 
In  the  Kensington  Survey,  77.4  per  cent,  of  the  3,198  persons  covere(? 
and  53.3  per  cent,  of  the  wage-earners,  carried  such  insurance,  prac- 
tically all  with  the  commercial  companies.  The  sickness  survey 
of  Western  Pennsylvania  was  made  among  such  industrial  policy- 
holders. This  industrial  life  insurance  is  to  guard  against  the 
dreaded  Potter's  Field  and  to  provide  for  decent  burial. 

In  1916  these  three  companies,  according  to  the  annual  report  of 
the  State  Department  of  Insurance,  issued  5,640,000  policies.  The 
number  of  policies  lapsing  was  nearly  half  as  many,  or  2,Jp0fi00. 
The  total  premiums  paid  these  companies  in  1916  amounted  to 
-1256,000,00.  They  paid  out  |78,000,000  in  claims  and  their 
excess  of  income  over  expenditures  was  reported  to  be  more  than 
17,000,000.00.1 

Of  these  5,640,000  policies  669,998  were  issued  in  Pennsylvania  for 
industrial  life  insurance.  Premiums  paid  for  these  during  the  year 
amounted  to  |22,526. 043.05.  More  than  twelve  times  as  many  poli- 
cies were  issued  in  the  industrial  branches  as  were  issued  in  the 
"ordinary  branches,"  although  the  amount  of  policies  in  the  "ordi- 
nary branches"  was  65  per  cent,  of  the  amount  of  the  industrial 
policies.  The  industrial  policies  which  ceased  to  be  in  force  during 
1916  number  over  400,000,  leaving  in  force  Dec.  31,  1916  in  the  indus- 
trial branches  of  these  three  companies,  5,326,107  policies,  amounting 
to  1678,956,915.00.  More  than  59,000  industrial  policies  had  been 
settled  during  the  year,  the  settlements  amounting  to  almost 
17,000,000.00.1 

The  184,725.58  paid  out  by  commercial  companies  for  sickness  and 
accident  claims  in  Pennsylvania  is  small  indeed  in  comparison  with 
these  sums.  It  is  frequently  estimated  by  advocates  of  compulsory 
health  insurance  that  the  average  employee,  for  the  same  sum  he 
now  pays  for  burial  insurance,  could  receive,  under  a  properly 
oganized  system  of  universal  health  insurance,  adequate  protection 
against  sickness  as  well  as  a  modest  funeral  benefit. 

The  purpose  of  commercial  insurance  companies,  from  the  stand- 
point of  the  directors  and  stockholders,  is  profit,  and  the  social  pur- 

(i)See  Table  V  and  VI  at  the  end  of  this  section. 


149 

jjose  is  secondary.  As  a  result  there  is  much  room  for  mismanage- 
ment in  writing  sickness  insurance  and  common  complaints  that  the 
contracts  are  narrow,  and  the  settlements  uncertain.  Many  com- 
panies insure  only  diseases  which  rarely  occur  and  many  of  the  most 
common  are  excluded ;  or  the  technical  clauses  modifying  the  agree- 
ment are  so  many  that  apparently  more  is  promised  than  paid. 
At  any  rate  it  is  too  oiten  true  of  this  type  of  carrier  that  the 
insured  fails  to  receive  his  benefit  when  he  most  needs  it. 

Mr.  H.  who  was  a  barber  with  a  wife  and  five  children  between 
five  and  fifteen  years  of  age,  fell  ill  with  tuberculosis.  During  his 
illness  the  family  expenses  were  met  by  the  irregular  earnings  of  his 
two  oldest  children,  but  it  was  also  necessary  to  obtain  some  help 
from  a  relief  society.  Mr.  H.  is  not  known  to  have  received  any 
medical  care  at  all.  He  was  insured  against  sickness  in  a  commer- 
cial company,  and  was  entitled  to  sick  benefits  of  flO.OO  a  week  for 
six  weeks,  but  the  company  claimed  that  Mr.  H.  had  chronic  bron- 
chitis, and  had  been  ill  with  it  when  he  took  out  his  policy,  and  they 
refused  to  pay  any  benefits. 

Abuses  to  which  health  insurance  by  commercial  companies  has 
lent  itself  are  indicated  by  the  state,  law  regulating  such  com- 
panies.^ 

The  law  expressly  excludes  "assessment  associations,"  fraternal 
societies  and  establishment  funds  which  are  non-commercial.  But 
casualty  companies  insuring  against  sickness  and  accident  are  not 
allowed  to  issue  policies  until  thirty  days  after  their  rates  are  filed 
with  the  Insurance  Commissioner.  All  benefits  payable  and  the  dates 
at  which  the  policy  comes  into  force  and  expires  are  to  be  named. 
The  minimum  size  of  the  printing  is  specified.  All  exceptions  must 
be  printed  with  the  same  prominence  as  the  benfits,  and  any  pro- 
visions for  the  reduction  of  benefits  in  certain  cases,  with  greater 
prominence.  The  practices  which  these  clauses  are  intended  to  pre- 
vent are  obvious. 

Fraternals  Carrying  Health  Insurance. 

By  far  the  largest  class  of  health  insurance  carriers  in  the  state 
are  the  fraternals.  Facts  regarding  health  insurance  carried  by 
fraternal  orders  have  been  compiled  from  the  Report  of  the  State 
Department  of  Insurance,^  and  from  a  study  of  sixty-eight  of  the 
most  prominent  and  representative  fraternals  operating  in  Pennsyl- 
vania. Forty-three  of  these  were  maintaining  sick  benefit  funds, 
about  which  detailed  information  was  secured. 

Each  large  fraternal  order  has  a  main  or  supreme  law-making 
body  to  which  all  its  locals  must  apply  when  desirous  of  amending 
a  law.  The  local  lodges  are  very  independent,  however,  and  are 
usually  left  free  to  regulate  the  details  of  administration. 


(') Public  Laws  of  Pennsylvania,   1911,   No.   667. 

(1)  According  to  two  statutes  of  April  6,  1803,  ceiiain  beneficial  societies  are  required  to  re- 
port to  the  State  Insurnnce  Commissioner  and  their  funds  are  exempted  from  State  taxation.  This 
does  not  apply  to  societies  formed  by  churches  or  corporations  to  which  only  their  members  or 
employees  can  belong,  or  to  the  sepret  beueftcial  societies  not  accepting  the  proylsions  of  the  act. 


150 

There  is  marked  similarity  between  these  fraternal  societies  and 
the  friendly  societies  of  Great  Britain  which  operate  under  the 
compulsory  health  insurance  law  established  there  in  1911,  but  unlike 
these  friendly  societies  the  membership  of  the  fraternals  in  this 
country  is  not  at  all  confined  to  the  so-called  working  class.  The 
Catholic  orders  in  all  probability  are  composed  in  large  measure  of 
wage  earners,  but  as  a  general  rule  with  the  exception  of  these  and 
certain  of  the  foreign  societies,  unskilled  and  low  paid  working- 
men  do  not  constitute  any  large  part  of  the  membership;  for  the 
most  part  the  fraternals  are  made  up  of  the  skilled  workmen  and 
professional  groups. 

There  are  two  general  types  into  which  the  fraternal  orders  are 
divided — the  social,  or  purely  fraternal  order,  and  the  insurance 
fraternal.  In  the  former,  small  irregular  sick  benefit  provisions  are 
made,  largely  by  the  local  bodies,  with  slight  minimum  require^ 
ments  from  the  main  order.  In  the  latter,  more  explicit  regulations 
for  the  sick  benefit  funds  are  enforced,  but  the  sick  benefit  is  a  mat- 
ter of  secondary  importance,  for  the  real  offering  of  the  insurance 
fraternals  is  life  insurance. 

In  all  fraternals  much  "brotherly  assistance"  is  rendered  which 
cannot  be  reported  in  statistical  tables,  or  i)rescribed  in  the  laws. 
Much  of  this  is  done  as  a  matter  of  charity.  Some  fraternals  have 
established  old-age  pensions,  and  it  is  not  unusual  to  find  that  large 
homes  are  maintained  for  the  aged  members  and  for  orphaned  chil- 
dren. 

The  fraternals  are  organized  on  a  basis  of  nationality,  religion, 
or  general  fraternal  rites.  The  fraternals  of  various  nationalities, 
Lithuanian,  Ukranian,  Slavonic,  exist  in  large  numbers  in  the  min- 
ing regions  of  the  state,  where  the  foreign  element  in  the  population 
is  large. 

There  are  usually  many  membership  qaualifications.  As  a  usual 
thing  the  members  are  restricted  to  an  age  group  of  from  sixteen 
to  fifty  years.  Occasionally  others  are  admitted  as  "honorary  or 
social"  members,  but  are  not  eligible  to  the  sick  or  death  benefits. 
In  addition  to  the  age  restrictions,  approximately  half  the  fraternals 
require  a  medical  examination  and  a  certificate  signed  by  a  physi- 
cian; in  other  cases  the  member  himself  swears  that  he  is  physically 
sound,  and  not  suffering  from  any  chronic  ailment.  Many  specific 
diseases,  varying  with  the  requirements  of  the  different  fraternals, 
exclude  applicants  from  membership.  In  almost  every  case  venereal 
diseases,  tuberculosis  and  any  chronic  trouble  are  excluded  as  well 
as  men  working  in  occupations  in  which  there  are  special  health 
hazards;  consequently  the  group  covered  by  such  insurance  as  the 
fraternals  offer  is  restricted  to  those  who  are  comparatively 
physically  fit  and  not  subject  to  recognized  occupational  hazards. 


151 

Weekly  lodge  dues  are  paid  in  most  cases,  although  some  few 
orders  have  quarterly  or,  as  was  found  in  one  instance,  yearly  dues. 
These  dues  are  generally  divided  into  four  parts — one  portion  goes 
to  the  main  body,  one  to  the  maintenance  expenses  of  the  local 
lodge,  pne  to  the  funeral  benefit  fund  and  one  to  the  sick  benefit 
fund.  In  the  case  of  these  fraternals  which  have  centralized  sick 
benefit  funds,  of  which  there  are  very  few,  the  sick  benefit  tax  is 
paid  by  the  local  to  the  main  body. 

The  eligibility  to  sick  benefit  depends  first  on  the  member's  stand- 
ing. If  he  is  behind  in  his  dues,  he  cannot  receive  his  benefit.  Sec- 
ond, if  he  has  not  belonged  to  the  fraternal  a  certain  length  of  time, 
he  is  not  eligible.  The  probation  period  is  usually  either  six  months 
or  a^yBar.  Third,  his  illness  must  be  of  sufficient  length  to  cover 
the  waiting  period,  usually  one  or  two  weeks.  In  other  words,  no 
benefit  is  paid  until  the  man  is  sick  two  weeks,  if  the  waiting  period 
is  one  week — or  sick  three  weeks,  if  the  waiting  period  is  two  weeks. 
In  only  one  case  was  it  found  that  benefits  were  paid  by  the  day; 
other  fraternals  paid  by  the  week,  disregarding  any  fraction  of  a 
week.  In  an  order  where  the  waiting  period  is  seven  days,  and  a 
member  is  ill  for  ibut  thirteen  days,  he  receives  nothing — if  he  is 
ill  for  twenty-seven  days  he  receives  two  weeks'  benefits.      v 

Only  three  of  the  fraternal  orders  studied  had  sick  benefits  which 
were  extended  to  the  dependents  of  a  lodge  member.  These  were 
medical,  not  cash  benefits,  and  in  two  instances  were  for  maternity 
care  only.  Many  fraternals  give  a  funeral  benefit  on  the  death  of  a 
member's  wife,  and  the  system  of  funeral  benefits  is  much  more  com- 
prehensive than  any  system  of  sick  benefits. 

The  possible  sick  benefits  are  of^t^aJdndszizdCaslL  and  medical. 
Four-fifths  of  the^odges  have  cash  benefits  only.  Three  fraternals 
had  regular  "lodge  doctors"  in  eveiy  local.  Others  reported  that 
the  matter  of  a  physician  rested^entirely  with  the  local  bodies — in 
one  case  50  per  cent,  of  these  local  bodies  had  their  doctors, — in 
another  case  25  per  cent. — and  so  on.  The  doctor  is  hired  on  a  per 
capita  basis.  He  usually  receives  fl.OO  a  year  per  member,  and  is 
then  responsible  for  all  illness  except  operations,  maternity  care, 
and  certain  "serious  diseases"  which  vary  in  the  different  fraternals. 
In  one  instance  an  arrangement  existed  with  a  "lodge  druggist"  sim- 
ilar to  the  arrangement  with  the  lodge  doctor.  Several  lodges  paid 
for  nursing  care  upon  occasion,  but  practically  always  as  a  matter 
of  charity. 

The  prevailing  cash  benefit  is  |5.00  a  week  for  thirteen  weeks  in 
any  given  year,  after  a  waiting  period  of  one  week.  Some  few  fra- 
ternals have  a  graded  scale,  and  pay  benefits  after  thirteen  weeks, 
occasionally  for  the  duration  of  the  illness.  Two  fraternals  reported 
a   scale   of  graded  membership,   according  to  the  amount   of   sick 


152 

benefit  desired,  and  the  occupation  of  the  member.  The  largest 
weekly  benefit  was  for  flO.OO.  This  was  paid  for  only  ten  weeks  in 
<one  year,  after  a  probation  period  of  twelve  months  and  a  waiting 
period  of  seven  days. 

Long  waiting  periods  and  special  qualifications  as  to  age  and 
physical  ability  are  necessary  in  order  to  fix  risks.  One  large  fra- 
ternal order  in  Pennsylvania  has  recently  centralized  its  Sick  Benefit 
Fund  in  order  to  distribute  more  evenly  the  sickness  burden. 
Before  this  centralization  the  cost  per  member  in  the  local  lodges 
varied  from  |5.88  to  |.08  according  to  the  ages  and  number  of  mem- 
bers, and  the  general  condition  of  the  local.  Now,  with  a  centralized 
system,  a  flat  rate  of  fl.SO  per  year  per  member  maintains  the  sick 
benefit  fund  and  allows  a  surplus  in  the  treasury  as  a  guard  against 
insolvency.  In  1917,  988  members  drew  4,613  weeks  of  sick  benefits 
from  this  fund.  This  was  about  six  per  cent,  of  the  membership. 
The  average  duration  of  sickness  was  five  weeks,  but  184  of  the  938 
drew  benefits  for  ten  weeks,  the  maximum  allowed  in  this  fund.  Of 
the  many  sicknesses  of  under  two  weeks'  or  over  ten  weeks'  duration, 
we  know  nothing. 

Isolating  three  of  the  sick  benefit  funds  whose  reports  were  fullest 
and  whose  waiting  period  was  one  week,  we  find  that  830  out  of  5,857 
members  were  ill  during  one  year,  or  approximately  one  out  of  every 
seven.     The  average  length  of  the  illness  was  five  and  a  half  weeks. 

So  far  as  wage  earners  are  concerned  this  type  of  health  insurance 
has  several  limitations.  First,  it  reaches  comparatively  few  in  the 
wage-earning  group.  Second,  it  is  bound  by  many  restrictive  rules. 
Third,  the  benefits  are  usually  inadequate,  and  seldom  include  medi- 
cal care.  Fourth,  the  lack  of  centralization  and  the  age  differences 
in  the  locals  make  the  benefit  funds  often  financially  unsound. 

Trade  Union  Funds  Carrying  Health  Insurance. 

Trade  Union  Sick  Benefit  Funds  afford  as  a  rule  even  less  protec- 
tion than  the  funds  of  the  fraternals.  In  both  types  of  insurance  the 
sick  benefit  is  secondary  to  the  death  benefit.  For  the  most  part  the 
establishment  of  sick  benefit,  funds  is  left  entirely  with  the  local 
unions,  although  nineteen  of  the  international  unions  are  known  to 
have  sick  benefit  systems.  Based  upon  studies  of  union  sick  benefit 
fiiuds  in  five  industrial  centers,  made  in  1917  by  the  Bureau  of  Labor 
Statistics  of  the  United  States  Department  of  Labor,  it  would  seem 
that  about  one  fourth  of  the  local  unions  in  existence  have  some 
scheme  for  the  payment  of  sick  benefits. 

Practically  all  trade  union  funds  limit  the  eligibility  to  sick  bene- 
fits to  members  in  good  standing  who  have  passed  a  probation  period, 
usually  of  six  months,  and  whose  disability  is  not  due  to  intemper- 
ance, debauchery,  or  other  immoral  conduct. 


153 

As  a  rule,  the  number  of  days  of  sickness  which  must  elapse  before 
the  payment  of  cash  benefits,  is  seven.  In  six  of  the  large  inter- 
national unions  it  is  fourteen.  More  than  three-fourths  of  the  funds 
studied  provide  a  sick  benefit  of  $5.00  a  week,  payable,  in  the  majority 
of  cases,  for  thirteen  weeks  in  a  single  year.  The  following  table 
shows  the  waiting  period,  the  maximum  benefit  period,  the  amount 
of  the  weekly  benefit  given,  and  the  average  annual  number  of  days  of 
disability  per  member,  in  sixteen  of  the  international  funds.^ 
These  regulations  are  typical  of  all  the  existing  trade  union  funds. 


Average  An- 

nual No. 

Maximum 

Weekly 

Disability 

Waiting   Period- (days). 

Benefit 

Benefit 
(in  dollars). 

Days  Per 

Period  (days). 

Member 

(all  dis- 

abilities). 

7,    - - 

78 

$12  00 

4.6 

7  (2),    

18» 

10  OO 

4.6 

112 

7  OO 

3.3 

7,    

91 

5  40* 

C') 

7,    

700 

5  00 

(8) 

7,    

91 

6  00 

3.7 

7,    

91 

50O 

(») 

7,    

91 

5  00 

3.6 

7,    —    __    —     -    

42 

5.00  (*) 

1.1 

7,    

7'J 

5.00 

(») 
3.1 

14.    

91 

6  00 

14,    

70 

600 

2.0 

14,    ^ 

112 

5  OO 

2.8 

14. 

84 

5  00 

1.7 

14,    

91 

4  00 

2.0 

14 . 

91 

300 

(») 

(2)  No  waiting  period  in  cases  of  disability  due  tg  accidents. 

(3)  No  record. 

(*)  Three  dollars  per  week  for  female  members.  d^ 

*This  organization  is  now  paying  a  weekly  benefit  of  $7.60. 

The  average  number  of  days  of  disability  varied  from  4.5  to  1.1, 
and  in  the  majority  of  cases  was  about  three  days.  It  must  be 
remembered  in  considering  these  figures  that  the  group  is  a  selected 
one,  and  that  only  disabilities  for  which  benefits  were  paid  are 
included.  Of  the  many  illnesses  lasting  less  than  the  waiting  period 
or  more  than  the  maximum  time  for  which  benefits  are  paid,  we  know 
nothing.  "^ 

Very  few  of  the  funds  furnish  their  disabled  members  with  any 
medical  care  or  supplies.  Occasionally  a  union  like  the  International 
^typographical  Union,  maintains  a  sanitorium  for  its  sick  members, 
but  in  almost  all  cases  the  fund  limits  its  benefits  to  small  cash 
payments. 


(>) Monthly  Review,    United  States  Bureau  of  Labor  Statistics,   August,   1917,   page  29. 


154 

Establishment  Funds  Carrying  Health  Insurance. 

The  most  complete  protection  seems  to  be  that  provided  by  some  of 
the  funds  maintained  within  individual  factories  or  establishments. 
These  are  of  several  kinds : 

1.  Funds  financed  and  managed  entirely  by  the  employees. 

2.  Funds  managed  by  the  employees,  to  which  the  employer 

makes  occasional  gifts. 

3.  Funds  financed  jointly  by  employer  and  employees,   and 

managed  jointly  or  controlled  entirely  by  the  employer. 

4.  Funds  financed  wholly  by  the  employer. 

In  the  last  two  types  membership  in  the  fund  is  frequently  a  com- 
l>ulsory  condition  >)f  employment. 

It  has  been  impossible  to  make  a  thorough  study  of  all  establish- 
ment funds  in  the  state,  but  the  experience  of  five  representative 
funds  in  Philadelphia  for  a  period  of  from  three  to  five  years  was 
examined,  and  figures  covering  twenty  Pennsylvania  funds  were 
taken  from  the  Establishment  Fund  Study  made  by  the  United  States 
Bureau  of  Labor  Statistics.  According  to  this  Bureau,  among  the 
till  establishments  in  the  state  employing  more  than  100  persons 
each,  there  were  in  December,  1916,  seventy- two  establishment  funds. 

The  dues  in  these  funds  usually  range  between  ten  cents  and  a 
dollar  per  week,  some  funds  having  several  membership  classes  in 
which  both  dues  and  benefits  are  graded  according  to  the  wage 
received.  In  many  cases  the  employer's  contribution  takes  the  form 
of  paying  the  cost  of  administration,  including  necessary  salaries. 
In  about  one-iialf  the  taids  studied  by  the  Bureau  of  Labor  Statistics, 
the  employers  made  contributions  toward  maintenance,  but  in  two- 
thirds  of  the  cases,  this  contribution  was  less  than  50  per  cent,  of  the 
cost. 

The  "period  before  eligibility  to  benefits"  is  non-existent  in  some 
funds,  but  in  others  may  be  as  long  as  three  or  four  months,  in  order 
to  exclude  the  casual  employee  and  the  malingerer.  These  long 
periods  are  often  prescribed  even  in  funds  where  membership  is  com- 
pulsory. ^ 

Benefits  begin  after  waiting  periods  of  from  three  days  to  a  week, 
and  usually  consist  only  of  cash  benefits  amounting  to  from  |3.00  to 
|15.00  per  week  and  payable  for  from  five  to  thirteen  weeks  in  each 
year.  Some  funds  pay  benefits  at  reduced  rates  from  the  end 
of  the  regular  benefit  period,  during  a  longer  specified  period  or  as 
long  as  the  illness  lasts.  Seventeen  of  the  twenty  PennsylvantH'f  unds 
in  the  Bureau  of  Labor  Statistics  Study  had  the  seven  day  waiting 
period,  which  predominated  among  all  the  funds.  Only  three  of  the 
Pennsylvania  funds,  or  15  per  cent.,  and  about  20  per  cent,  of  all  the 
funds,  supplied  medical  treatment.  In  all  but  some  five  per  cent,  of 
the  funds  throughout  the  country,  moreover,  medical  care  as  reported 


\ 


155 

^^  as  confined  to  /ninor  surgical  operations,  supplies  and  a  single  visit 
I'rom  the  physician.  The  average  weekly  cash  benefit  paid  by  the 
Pennsylvania  funds  was  |8.32.  Death  benefits  of  from  |75.00  to 
1500.00  are  usually  paid. 

This  type  of  insurance,  as  would  naturally  be  expected,  is  most 
often  found  in  the  larger,  more  progressive  establishments,  especially 
the  railroads,  telephone  companies,  department  stores  and  steel  mills. 
One  large  group  of  workers,  the  miners,  seem  to  be  almost  entirely 
untouched  by  it,  only  one  company  having  been  found  to  be  main- 
taining such  a  fund,  and  one  other  company  having  taken  out  a 
group  policy  with  a  commercial  company. 

The  members  of  the  employee's  family  are  rarely  if  ever  included  in 
such  a  fund,  although  occasionally  medical  and  nursing  care  are  sup- 
plied to  them  at  reduced  rates. 

In  comparison  with  trade  union,  fraternal,  and  commercial  health 
insurance,  the  establishment  fund  gives  more  adequate  and  certain 
cash  benefits  and  is  more  simple  in  administration.  Its  weakness  is 
its  usual  lack  of  provision  for  medical  care  and  its  common  restriction 
to  employees  in  the  better  managed  establishments. 

Results  of  the  surveys  show  conclusively  the  limitations  of  existing 
health  insurance  facilities. 

A  study  "of  the  existing  insurance  shows  that  it  is  carried  mainly 
by  the  wage-earners  of  the  family,  that  insurance  in  fraternals  is 
most  popular,  and  that  most  of  it  provides  only  a  small  weekly  cash 
benefit,  medical  treatment  being  seldom  supplied. 

The  tendency  to  insure  only  tvage-earners  is  illustrated  by  the  fact 
that  in  western  Pennsylvania  and  West  Virginia,  while  40.6  per  cent, 
of  the  iron  and  steel  employees  and  about  30  per  cent,  of  the  anthra- 
cite and  bituminous  miners  were  insured,  only  17  per  cent,  of  the 
bituminous  miners'  families  wSre  insured  and  12  per  cent,  of  the 
anthracite  miners'  families. 

In  the  Kensington  Survey,  while  34  per  cent,  of  the  wage-earners 
were  insured  against  "sickness  and  death,"  only  17.4  per  cent,  of  the 
total  number  of  persons  covered  were  protected  in  that  way.  Twelve 
dependents,  as  against  ninety-two  wage-earners,  carried  sickness 
insurance  in  the  893  Sickness  and  Dependency  families. 

An  analysis  of  the  benefits  provided  by  health  insurance  in  the 
Sickness  and  Dependency  Study  shows  that  a  cash  benefit  of  f5.00, 
fO.OO  or  17.00  a  week  was  the  usual  return.  The  maximum  period 
during  which  benefits  were  payable  was  between  six  and  thirteen,  and 
between  thirteen  and  twenty-six  weeks  a  year,  in  about  an  equal  num- 
ber of  cases.  Although  the  importance  of  adequate  medical  care  in 
shortening  the  period  of  illness  and  improWng  health  is  universally 
recognized,  medical   benefits  were  pro\1ded  by  only  a  fifth  of  the 


156 

policies.  Except  one  establishment  fund,  which,  gave  sanitarium 
treatment  when  needed,  this  took  the  form,  in  all  cases,  of  medical 
treatment  by  the  factory  or  "lodge"  doctor. 

The  cost  of  insurance  in  this  study  was  known  in  only  thirty-one 
families.  Although  this  number  is  too  small  for  definite  conclusions, 
it  may  be  mentioned  that  in  fifteen  cases  it  was  between  ten  and 
twenty-five  cents  a  week,  in  nine,  between  twenty-five  and  fifty  cents, 
and  in  five,  between  fifty  and  seventy-five  cents.  It  would  seem  that 
by  their  unaided  voluntary  efforts,  Pennsylvania  employees  are  not 
at  present  able  to  purchase  health  insurance  having  adequate  benefits. 

Another  serious  limitation  of  health  insurance  as  it  exists  in  Penn- 
sylvania today  is  found  in  the  restrictive  rules  of  many  benefit 
'  societies,  which  often  prevent  the  receipt  of  benefits  in  time  of  need. 
It  is  noteworthy  that  in  the  Sickness  and  Dependency  Study, 
although  some  form  of  health  insurance  was  carried  in  101  families, 
only  sixty-nine  were  in  actual  receipt  of  benefits.  One  woman  was 
even  refused  benefits,  though  unable  to  work,  because  she  went  to  the 
hospital  to  have  her  tubercular  glands  dressed,  and  was  therefore 
"not  confined  to  the  house."  Other  and  more  legitimate  reasons  for 
refusal  were  arrears  of  dues,  the  initial  waiting-period,  and  the 
alleged  existence  of  the  disease  at  the  time  of  joining  the  society. 

Mr.  B.,  a  structural  iron  worker  whose  wage  was  $5.00  a  day  but 
whose  work  was  irregular,  was  ill  and  out  of  work  for  four  months 
on  account  of  sciatica.  The  family  soon  exhausted  their  own 
resources.  They  then  received  help  from  a  national  society  and  from 
a  relief  agency,  which  secured  free  hospital  care  for  Mr.  B.  and  aided 
in  the  support  of  the  family.  Mr.  B.  belonged  to  a  fraternal  sick 
benefit  society,  to  which  he  paid  flO.OO  a  year,  but  he  could  obtain 
no  benefits  as  he  had  fallen  somewhat  behind  in  dues. 

In  the  study  of  the  110  Mothers'  Assistance  Fund  Families, 
although  there  were  thirty-two  policies  calling  for  health  insurance 
during  the  father's  illness,  the  -benefits  had  been  paid  in  but  twenty 
cases.  Because  the  others  were  behind  in  their  dues,  or  had  excluded 
diseases,  or  had  violated  some  rule  of  the  insurance  organization, 
benefits  had  been  refused. 

Extent  of  Health  Insurance  in  Pennsylvania. 

Sickness  surveys  show  that  while  a  consideraMe  minority  of  tvage- 
earners  have  already  turned  to  health  insurance  as  a  means  of  pro- 
tection from  the  effects  of  sickness,  it  has  developed  least  a/tnong 
those  who  need  it  most.  They  shoiv  also  that  existing  health  insur- 
ance pays  hut  small  benefit.^  and.  is  limited  in  usefulness  by  the  many 
restrictive  rules  which  have  been  discussed. 

The  percentage  of  persons  protected  by  some  form  of  health  insur- 
ance was  considerably  higher  in  the  Kensington  and  the  Western 
Pennsylvania  Surveys  than  in  the  other  Surveys. 


157 

In  Western  Pennsylvania  and  West  Virginia,  30.7  per  cent,  of  the 
males  fifteen  years  of  age  and  over  were  in  receipt  of  some  form  of 
sick  benefits.'  In  Pittsburgh  the  figure  was  29.4  per  cent.  How- 
ever benefits  paid  under  the  Workmen's  Compensation  law  as  well  as; 
under  voluntary  health  insurance  are  included  in  these  figures.. 
Since  disability  from  accident  was  very  prevalent  among  the  Westerni 
Pennsylvania  workmen,  to  find  the  real  extent  of  health  insurance  a 
considerable  deduction  from  these  figures  should  in  all  probability 
be  made.  In  the  Kensington  district  of  Philadelphia,  however,  no 
less  than  34.9  per  cent,  of  all  the  wage-earners  covered  carried  some 
form  of  insurance  against  sickness. 

In  the  study  of  Mothers'  Assistance  Fund  Families  29  per  cent,  of 
the  fathers  carried  some  form  of  health  insurance,  in  the  Visiting 
Nurse  Study,  18  per  cent,  of  the  families  had  this  protection ;  in  the 
Working  Women's  Study  but  12  per  cent,  of  the  women  carried 
health  insurance. 

In  contrast  to  the  extent  of  insurance  among  ordinary  groups  of 
employees,  is  the  fact  that  of  the  893  Philadelphia  families  in  the 
Sickness  and  Dependency  Study,  of  which  an  extensive  study  was 
made  in  the  previous  section,  only  11  per  cent,  carried  health  insur- 
ance of  any  kind ;  only  ninety-two  of  the  wage-earners  were  insured, 
while  by  no  means  all  of  the  persons  insured  actually  received  insur- 
ance benefits.  Among  the  418  charity  illness  cases  studied  by  the 
Bureau  of  Social  Research,  insurance  was  found  in  only  19  per  cent, 
of  the  300  about  which  the  fact  was  ascertained.  Moreover,  health 
insurance  was  least  often  carried  by  the  wage-earners  having  low 
incomes,  who  are  most  likely  to  need  additional  resources  in  time  of 
illness.  While  the  numbers  involved  are  small,  so  that  conclusions 
should  be  guarded,  the  difference  is  striking.  In  thirty-seven  families 
with  incomes  of  over  |15.00  a  week,  insurance  was  carried  in  eleven, 
or  30  per  cent.  In  179  receiving  less  than  |15.00  a  week,  insurance 
Vas  carried  in  only  twenty-two  or  12  per  cent.  It  has  been  pointed 
out  in  discussing  sickness  as  a  factor  in  destitution,  that  the  majority 
of  these  families,  containing  a  high  proportion  of  young  children  and 
fewer  wage-earners  than  the  average,  are  living  through  the  time 
when  the  strain  on  family  expenses  is  heaviest  and  the  fewest 
resources  exist.  In  view  of  this  fact  and  the  small  percentage  of 
insurance  among  the  low  wage  group,  it  can  rightly  be  said  that 
under  present  voluntarj^  methods,  those  who  most  need  health  insur- 
ance are  least  likely  to  carry  it. 

The  predominance  of  lodge  and  fraternal  societies  as  the  carriers 
of  health  insurance  among  employees  was  clear  in  each  study.  In 
Western  Pennsylvania  52  per  cent,  of  the  insurance  wias  of  that 
variety,  in  Pittsburgh  alone,  53  per  cent,  and  in  the  Kensington  Sur- 


(1)  statistics  for  Western  Pennsylvania  alone  are  not  given. 


158 

vey  no  less  than  73  per  cent.  Sixty-seven  of  the  103  policies  found  in 
the  893  dependent  families  were  with  fraternals,  and  thirty -nine  of 
fifty-four  policies  in  the  families  studied  by  the  Bureau  of  Social 
Research.  In  the  study  of  working  women  forty  out  of  forty -eight 
policies  were  with  fraternals,  and  in  the  Mothers'  Assistance  Fund 
Study  over  50  per  cent,  were  held  in  these  lodges.  Doctors  and 
employers  in  the  mining  districts  reported  that  from  50  to  90  per 
cent,  of  the  miners  were  carrying  fraternal  health  insurance. 
Besides  this  type  of  carrier  the  number  of  trade  union  funds  and 
other  carriers  found,  is  insignificant. 

Taking  the  figures  found  in  the  Western  Pennsylvania  Survey  as 
the  most  representative  for  the  state  as  a  whole,  we  find  that  of  the 
685  cases  in  receipt  of  sick  benefits,  365,  or  52  per  cent.,  were  being  paid 
by  fraternal  societies  or  lodges.  Establishment  funds,  or  employers 
directly,  were  paying  sick  benefits  in  11.4  per  cent,  of  the  cases; 
commercial  insurance  companies  in  8.0  per  cent,  and  trade  unions  in 
8.6  per  cent.  Miscellaneous  groups  of  other  agencies,  including 
Workmen's  Compensation,  provided  for  20.5  per  cent,  of  the  total 
number  of  persons  in  receipt  of  any  kind  of  benefit.'. 

It  can  he  concluded  that  not  more  than  SO  per  cent,  of  the  icage 
earners  carry  any  insurance  protection  against  the  sickness  risk; 
that  more  than  half  the  irisurance  carried  is  of  the  fraternal  type; 
that  trade  union  funds,  commercial  insurance  companies,  estahUsh- 
Wtent  funds  and  miscellaneous  agencies  account  for  the  remaining 
half;  that  the  insurance  is  canied  hy  the  hetter-paid  and  more  highly 
skilled  workmen,  is  seldom  extended  to  dependents,  and  rarely  affords 
either  medical  care  or  adequate  cash  benefits. 


(1)  Table  —  at  end  cf  section  contrasts  types  of  benefit  receivod  in  the  various  survey^. 


:>    o  J   5' 


Vta^le  I. 


159 

Part  II,   Section  III,   Table  II. 
HOSPITAL  BED  ACCOMODATION. 


County. 


61 


Adams,    

Allegheny.    

Armstrong,   

Beaver,    

Bedford,    

Berks,  

Blair,    - 

Bradford,     — . 

Bucks,    

Butler,    

Cambria,    

Carbon,   

Cameron,    

Centre,     

Chester,  

Clarion,  

Clinton,    

Columbia,    

Crawford,    

Cumberland,     — 

Dauphin,   

Delaware,    

Elk,    

Erie,    

Fayette,    

Forest,    

Franklin,    .. 

Fulton,    

Cireene,   

Huntingdon,    — 

Indiana,    a 

Jefferson,     

Juniata,    

Lackawanna,    

Lancaster,    

Lawrence,  

Lebanon,    

Lehigh,    

Luzerne,    

Lycoming,    

McKean,    

Mercer,    

Mifflin,    

Montgomery,    __ _ 

Montour,    

Monroe,   

Northampton,    __ 
Northumberland , 

Perry,  

Philadelphia,    ___ 

Pike,    

Potter,     

Schuylkill,    

Snyder,    

Somerset,    

Sullivan,    

Susquehanna,     — 

Tioga,    

Union.    

Venango,    

Warren,     

Washington,     ___ 

Wayne,    

Westmoreland,    _ 

Wyoming,    

York,    

Clearfield,  


Beds  in  Public  Hospitalo. 


Total, 


Beds  Per 

1.000 
Population. 

General. 

Special. 

Total. 

0 

0 

0 

.0 

4,859 

1,199 

6,058 

5.9 

24 

0 

24 

.35 

171 

141 

312 

S.9 

0 

0 

0 

.0 

360 

910 

1,270 

1.9 

345 

0 

345 

3.1 

155 

0 

155 

2.8 

0 

0 

0 

.0  - 

55 

0 

55 

.75 

257 

419 

676 

4.6  (1.7) 

0 

0 

0 

.0 

0 

0 

0 

.0 

88 

0 

88 

2.0 

^285 

820 

1,105 

2.6 

^      0 

0 

0 

.0 

80 

0 

80 

2.5 

110 

0 

110 

2.2 

125 

0 

125 

2.0 

49 

0 

49 

.90 

171 

1,486 

1,657 

4.8  (1.2) 

250 

750 

l.OCO 

2.1 

40 

0 

40 

1.1 

440 

87 

527 

4.5 

188 

0 

188 

1.1 

0 

0 

0 

.0 

60 

1,040 

1,100 

18.3  (1.0) 

0 

0 

0 

.0 

20 

0 

20 

.69 

52 

0 

52 

1.3 

50 

0 

50 

.75 

110 

0 

110 

1.7 

0 

0 

0 

.0 

453 

flS 

521 

2.07 

710 

0 

710 

4.2 

143 

0 

143 

2.0 

100 

0 

lOO 

1.6 

227 

1,000 

1,227 

1.0 

639 

33 

672 

1.9 

214 

0 

214 

2.6 

179 

37 

216 

4.5 

79 

0 

79 

1.0 

44- 

0 

44 

1.6 

261 

2,7ay 

2,991 

1.5 

75 

1,450 

1,525 

5.04 

30 

0 

30 

1.3 

215 

0 

215 

1.7 

112 

0 

112 

1.0 

0 

0 

0 

0 

6,867 

2,802 

9,659 

6.2 

0 

0 

0 

.0 

41 

0 

41 

1.3 

303 

0 

363 

1.7 

0 

0 

0 

.0 

40 

0 

40 

.59 

0 

0 

0 

.0 

19 

0 

19 

.50 

45 

0 

45 

1.05 

0 

0 

0 

.0 

90 

1,692 

1,7^ 

1.7 

171 

1,282 

1,458 

4.3 

228 

0 

228 

1.6 

0 

500 

500 

.0 

195 

0 

195 

.84 

0 

0 

0 

.0 

124 

0 

124 

.91 

120 

0 

120 

1.2 

20,118 

18,449 

38,584 

3.4 

"Special"  and  "Total"  include  State  insane  hospitals.  Insane  hospitals  are  not  included  in 
"number  beds  per  1,000  population."  Figures  in  parenthesis  indicate  number  of  beds  per  1,000 
exclusive  of  State  tuberculosis  sanatoria. 

If  we  consider  the  population  of  Pennsylvania  in  1918  as  8,991,175,  number  of  beds  taken 
from  1917-18  directories  we  may  consider  the  present  number  per  1,000  population  as  2.9. 
Total  hospital  beds  not  including  Insane,  26,721. 

11 


160 


Part  II. 


-Section  III. — Table  III. — Kinds  of  Medical  Care  Received  in  Sickness 
Cases   Covered   by  Various   Pennsylvania   Surveys.^ 


Kinds   of  Treatment. 

Western 
Pennsyl- 
vania 
Survey. 2 

Pittsburgh 

Sickness 
Survey. 

Philadelphia 

Survey. 

Kensington 
Survey. 

Sickness 

and 

Dependency 

Study. 

Unknown               -            

93 

48 
154 
28 
116 
675 
85 
58 
15 

29 

1,86ft 

452 

24 

Patent   medicines, 

23 
89 
236 
22 
48 

Private  physician           - 

3,445 
529 
59 

m 

1,208 
200 

337 

BLospital  or  sanitarium,   

435 
421 

Nurses  (visiting) , 

87 

Midwife         -     

3 

13 

Dentist,    

180 

9 

11 

15 

District  doctor,        ' 

119 

12 

Convalescent  home. 

71 

Nurse,   other, 

9 

Drug  store,  doctor,             

18 

Factory  doctor,      _    

^' 

12 

Part  II. — Section  III. — Table  IV-A. — Number  and  Amount  of  Sickness  Claims  Paid 
by  Fraternal  and  Commercial  Insurance  Companies  Supervised  by  the  State 
Insurance  Department,   1916. 

ASSESSMENT     SICK    BENEFIT    AND    ACCIDENT    ASSOCIATIONS    OF 
OTHER  STATES  OPERATING  IN  PENNSYLVANIA. 


Name  of  Company. 


Claims 
Paid, 
1916. 


Columbia  Protective  Association,  

Detroft  Casualty  Co.,   

Praterna]  Protectve  Association,  Inc.,  

Fidelity  Health  and  Accident  Insurance  Co.,  — 

Home  Accident  and  Health  Insurance  Co.,  

Hoosier  Casualty   Co.,   

Inter-state  Business  Men's  Accident  Association,' 

Massachusetts   Indemnity   Co.,    

Masonic  Mutual  Accident  Co.,  

National    Benefit   Association,    

National  Accident  Society,   

Royal  Mutual  Aid  Beneficial  Association,  

St.   Lawrence  Life  Association,  

United  States  Indemnity  Society,  

Union  Casualty  Co.,   

Wisconsin   Casualty  Association,    


121 

$1,388  09 

151 

2,825  47 

729 

27,000  62 

153 

3,068  71 

12 

164  32 

246 

3,715  20 

3 

10,500  00 

8 

351  85 

184 

5,040  69 

2,447 

15,213  02 

li>l 

3,079  46 

98 

522  00 

76 

1,219  77 

143 

2,366  00 

337 

6,734  23 

70 

1,548  16 

4,924 

$84,725  59 

1  In  some  cases,  more  than  one  kind  of  medical  care  was  received. 

2  White  persons  only. 


IGl 


PART  II.— SECTION  III.— TABLE  IV-B. 

FRATERNAL,    BENEFICIAL  AND  RELIEF  SOCIETIES  OF 

PENNSYLVANIA. 


Name  of  Company. 

Claims 
Paid, 
1918. 

Amounts. 

American  Ch°ckw°ight  and  Voluntary  Relief  Association, 

5 

$46  CO 
2,758  OO 

First  Hungarian  R€formed  Sick  Benefit  Society,   _       

Fraternal    Mystic   Circle    (Supreme   Ruling),    _      ___    _    _ 

208 
3,182 
107 
406 
126 
106 
20 
256 

6,460  52 

German  Roman  Catholic  Knights  of  St     George, 

71,533  50 
4,096  70 
8,919  11 
4,560  50 

14,588  00 
451  96 

Independent  Order  of   Puritans,    ,__ 

Lithuanian  Roman  Catholic  Alliance  of  America, 

National  Croatian  Society  of  the  United  States  of  America,  

Slavonic   Evangelical   Union   of  America,    _    _ 

Verhovay   Aid  Association,             _  _    _ 

6,242  00 

4,416 

$119,665  29 

PART  II.— SECTION  III.— TABLE  IV-C. 
SECRET  FRATERNAL  BENEFICIAL  SOCIETIES 


Name  of  Company. 


Educators'  Beneficial  Association 
Fort  Pitt  Mutual  Life  Insurance  Co. 
German   Beneficial   Union 
The  Grand   Fraternity 
Guild  of  the  East 
The  Home  Beneficial   Society 
Keystone   Fraternal    Union, 
National    Fraternal    League, 

National   Home   Guard,    

Royal   Fellowship,   

Security  Industrial  Life  and  Benefit  Association, 

Standard   Protective   Society,    

Teachers'  Protective  Union,   


$65,319  80 


162 


PART  II.— SECTION  III.— TABLE  IV-I). 
FRATERNAL,     BENEFICIAL     AND     RELIEF     SOCIETIES 
STATES    OPERATING    IN    PENNSYLVANIA. 


OF     OTHER 


Name  of  Company. 


Aid  Association   for  Lutlierans,    

American  Insurance  Union,  

The  American  Workmen,   

Benevolent  Order  of  Egyptians,   

Brotherhood  of   American   Yeomen,    

Brotherhood  of  All  Railway  Employees,   

Catholic   Fraternal  League,   

Catholic  Relief  and  Beneficiary  Association,   

The  Columbian  Circle, 

Columbia  Fraternal  Association,   

Court  of  Honor,   

Fraternal  Benefit  League,   

Fraternal  Brotherhood  (Supreme  Lodge),  

German  Baptists   Life  Association,   

Grand  Carniolian  Slavonian  Catholic  Union  of  U.  S.  A 

Independent  Order  of  Foresters,   

Independent  Workmen's  Circle  of  America,   

Jewish  National  Worker's  Alliance  of  America,   

Loyal  Mystic  Legion  of  America,   

The  Maccabees,  

Modern  Brotherhood  of  America,  

Modern  Order  of  Praetorians,   

National  Benevolent    Society,    

National  Fraternal  Society  of  the  Deaf,  

National  Protective  Union,    

North  American   Union,    . 

Order  of  the  Golden  Seal,  — — 

Order  of  United  Commercial  Travelers  of  America, 

The  Patricians,  

Royal  Fraternal  Association,    

Slovenic  National  Benefit  Society,  

Slovenic  Progressive  Benefit   Society,    

South   Slovenic   Catholie   Union,    

United  Artisans,  

Woman's  Benefit  Association  of  the  Maccabees,   — 

Workmen's  Sick  and  Death  Benefit  Fund  of  U.   S.   A., 

Workmen's  Circle,   

Travelers'  Protective  Association  of  America,   

United  Insurance  Society,   


110 
(Not  given 
forPenna.) 
56 
3 
46 
5 
75 
13 
55 
447 

(Not  given 
forPenna.) 
12 

(Not  given 
forPenna.) 
1 
*157 


(Not  given 

forPenna.) 

(Not  given 

forPenna.) 

(Not  given 

forPenna.) 

5 

13 

510 

(Not  given 

forPenna.) 

399 

123 

(Not  given 

forPenna.) 

(Not  given 

forPenna.) 

1,769 


(Not  given 

for  Penna.) 

2 

1,577 

017 

206 


Amounts. 


$231  00 
2,500  12 


1^48  25 

54  70 

1,221  21 

235  00 

2,318  00 

7,6S1  15 

553  DO 

12,116  38 


420  33 


60  OO 

*3,441  31 

15,180  50 

1,048  OO 

200  00 


81  10 

185  00 

15,233  63 


8,357  41 
8,635  43 


39,837  GO 
11,705  30 
13,443  62 


60  00 

46,324  75 

14,190  DO 

15,544  58 

180  00 


$221,996  80 


Name  of  Company, 

Olaims 
Paid, 
1910. 

Amounts. 

Assessment  sick  benefit  and  accident  associations  of  other  states  (16), 
Fraternal,  beneficial  and  relief  societies  of  Penna.   (10),  _    — 

4,924 
4,416 
2,544 

7,990 

$84,725  59 
119,605  29 

Secret  fraternal  beneficial  societies  (13), 

65,319^ 

Fraternal,  beneficial  and  relief  societies  of  other  states  (40)t,  

221,996  80 

79  societies,!  Totals,     .    

19,874 

$492,707  48 

*Sicknes'S  and  funeral  claims  Jn  ^  lupip  surn, 
tFigures  for  30  only, 
JFigures  for  69  only. 


163 

PART  II.— SECTION  III.— TABLE  V. 
CERTAIN  STATISTICS  OF  PRINCIPAL  COMMERCIAL  INSURANCE  COM- 
PANIES   CARRYING    INDUSTRIAL    LIFE    INSURANCE,    191G. 


No.  of  policies  issued,  

No.  of  policies  lapsed,  

Premiums— first    year,    

Premiums— renewals,     

Total   premiums,   

Claims    paid,    

Excess  of  income  over  expenditure 


Name  of  Company 


John  Hancock 


552,873 

261,546 

2,198,195.80 

28,649,018.40 

30,847,214.20 

9,981,707.91 

13,358,729.72 


Metropolitan 


2,516,062 
1,059,933 
10,585,770.80 
114,675,546.83 
125,261,317.72 
39,058,657.99 
64,106,518.53 


Prudential 


2,574,537 
1,149,373 
6,429,697.59 
93,560,493.90 
99,990,191.40 
29,739,979.40 
42,247,637.81 


Total 


5.643,472 

2,470,822 

19,213,664.28 

236.885,059.13 

256,096.723.41 

78,780,345.30 

119.714.886.06 


164 


S8 

is 


8      88 


i      i 


88 


CO  I-l  I-H 


rH  C00> 


8      8 


cjeo 


88 


8       88 


8      ^S 


S    88 


88 


8       88 


88 


sg 


lr-00 

SS5 


-^s? 


00  o 


8       88 


8       8S 


88 


8       8 


■S§3 


F 


CO  t^ 


m 


^         *r-( 


60    >X] 


«o^ 


5      .ja 

•^  S  >>.s 

S.S'P'o 


O         .X5 

§  li 

<y     ^« 

^  a  >».s 

C3  tH  03+J 

53  S  a  g 

to 
O 


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aSa 


m 

333-0 


2 


165 

PART  II.— SECTION  III.— TABLE  VII. 
Kinds  of  Health  Insurance  Carried,    According  to  Pennsylvania  Sickness  Surveys. 


Kinds   of  Insurance. 


PenfiByl- 

Piittsbureh 

Kensington 

Sickness 

Bureau  for 

vanla.  (i) 

(^) 

Survey. 

and  Depend- 
ency, t 

Social 
Research. 

i 

8 

s 

S 

S 

3 

'3 

"3 

^ 

« 

K 

*> 

^ 

^ 

a 

^ 

a' 

^ 

^ 

«j 

■3 

§ 

O 

i 

«M 

o 

i 

o 

i 

o 

g 

o 

S 

o 

^ 

o 

fe 

6 

fc 

o 

» 

iz; 

Oh 

» 

A^ 

^ 

A^ 

5^ 

|i< 

;2; 

Ah 

Lodges   and   fraternal  so- 
cieties.  

356 
59 
78 
55 

137 

52.0 
8.6 

11.4 
8.0 

20.0 

116 
23 
37 
27 
16 

53.0 
10.5 
16.9* 
12.3 
7.3 

452 
50 
96 
18 

73.3 
8.2 

15.6 
2.9 

67 
9 
14 
8 
••5 

65.0 

8.7 

13.6 

7.8 

,      4.8 

39 
5 
10 

Trade  unions,   _    ._      

Establishment  funds,   

Commercial   companies,    _. 

Otlier, . 

Total,     

685 

100.-0 

219 

100.0 

616 

100.0 

103 

100.0 

54 

♦Including  all  forms  of  assistance  from  employers. 
**Kind  unknown. 
***Numbers  too  small  to  compute  percentage. 

tFigures  for  Philadelphia. 
(i)Flgures  for  males,  fifteen  years  and  over. 


M 


y 


(166) 


PART  II. 
SECTION  IV. 

Influence  of  Working  Conditions  on  Health. 


(167) 


(168) 


169 

INFLUENCE  OF  WORKING  CONDITIONS  ON  HEALTH. 

Dr.  Alice  Hamilton,  of  the  United  States  Bureau  of  Labor  Sta- 
tistics, has  written  for  the  Commission  a  report  on  the  principal 
Pennsylvania  industries  in  which  abnormal  hazards  to  health  are 
present.  The  value  of  this  work  from  so  authoritative  a  source  can 
hardly  be  overemphasized,  especially  as  existing  material  on  local 
conditions  is  very  scant,  and  time  and  money  for  first-hand  investi- 
gations are  lacking. 

In  addition  to  this  study,  which  deals  with  the  relation  between 
specific  industrial  processes  and  certain  definitely  recognized  occu- 
pational diseases,  other  facts  have  been  collected  which  show  the 
influence  that  conditions  of  occupation  may  and  often  do  have 
upon  the  general  health  of  the  workers.  Aside  from  the  dangers 
presented  by  industrial  poisons,  there  are  innumerable  other  factors 
connected  often  with  the  place  of  employment  and  the  methods  of 
work,  but  not  necessarily  inherent  in  the  industrial  process, — among 
them,  ventilation,  sanitation,  temperature,  posture,  illumination, 
fatigue, — over  which  the  employee  has  little  if  any  control,  but  which 
affect  him  in  varying  degrees,  according  to  the  nature  of  his  occu- 
pation and  the  surroundings  in  which  he  works  and  lives.  "The 
wage-earner  sells  to  his  employer,  not  merely  so  much  muscular 
energy^  or  mechanical  ingenuity,  but  practically  his  whole  existence 
during  the  working  day.  An  over-crowded  or  badly  ventilated  work- 
shop may  exhaust  his  energies,  sewer  gas  or  poisonous  material  may 
undermine  his  health,  a  badly  constructed  plant  or  imperfect  machin- 
ery may  maim  him  or  even  cut  short  his  days;  coarsening  surround- 
ings may  brutalize  his  life  and  degrade  his  character;  yet,  when  he 
accepts  ein]:loyment,  he  tacitly  undertakes  to  mind  whatever  machin- 
ery, use  whatever  materials,  breathe  whatever  atmosphere,  and  endure 
whatever  sights,  sounds  and  smells,  he  may  find  in  the  employer's 
Avorkshop,  however  inimical  they  may  be  to  health  and  safety."^ 

"Aside  from  famil}^  Avays  of  living  and  bad  places  to  live  in,  there 
are  many  conditions  of  labor  which  reduce  the  health  and  weaken 
the  resistance  of  the  individual,  making  him  susceptible  to  infectioji 
and  making  him  and  his  descendents  less  likely  and  able  to  bring 
into  the  world  and  rear  healthy,  robust  children.  The  true  signifi- 
cance of  many  bad  conditions  of  labor  relates  to  the  demoraliza- 
tion of  the  health,  morals  and  social  status  of  the  individual  and  to 
home  conditions  from  inadequate  wages."^ 

The  effects  of  many  such  harmful  conditions  of  employment  are 
not  generally  appreciated  or  understood.  In  the  absence  of  any  sud- 
den or  spectacular  illness,  the  slow  development  of  premature  old 
age.  blindness,  rheumatism,  and  degenerative  diseases  of  the  lungs, 

(MReatrirp   and   Sidney   Webb,    "Industrial   Democracy,"   volume   11,   pape   354. 
(2)The  Underlying  Factors   in   the   Spread   of  Tuberculosis.    Dr.   Albert  P.    Francine,    9th   Annual 
Report  of  Commissioner  of  Health  of  Penna.,   1914,  page  147. 


170 

heart  and  kidneys  may  proceed  without  the  attempt  being  made  to 
seek  their  cause  in  the  factory  or  workshop.  In  Pennsylvania,  in 
1916,  of  58,703  deaths  of  persons  of  working  age,  between  20  and  70 
years,  46,714,  or  79.5  per  cent.,  were  from  causes  which,  according 
to  Dr.  Emery  R.  Hayhurst  of  the  Ohio  State  Board  of  Health,  "would 
not  bear  scrutiny  as  either  timely  or  justifiable,"  and  which  in  his 
study  of  Industrial  Health  Hazards  in  Ohio  he  considers  to  a  certain 
extent  indicative  of  the  effects  of  occupation. 

PENNSYLVANIA,  1916,  DEATHS  FROM  CERTAIN  CAUSES  OF  PERSONS 
BETWEEN  20  AND  70  YEARS  OF  AGE. 


Cause  of  Deaths. 


Number 

of 
Deaths. 


Tetanus,   

Tuberculosis  (total),  

Cancer, 

Rheumatism, 

Anemia,  _*. 

Alcoholism,  

Nervous   diseases, 

Organic  heart  disease,  

other  circulatory  diseases,  

Lung  diseases  (other  than  tuberculosis) , 

Bright's  disease,  

8kin  diseases,  

External  causes, 


55 

8,641 

4,791 

277 

S59 

485 

5,480 

6,899 

1,933 

5,536 

5,285 

172 

6,801 


One-sixth  of  these  deaths  were  due  to  diseases  of  the  circulatory 
system,  and  one-eighth  to  organic  heart  disease  alone.  All  diseases 
of  the  circulatory  system,  and  particularly  organic  heart  disease,  are 
in  the  majority  of  cases  preventable  and  worthy  of  investigation  as 
to  cause  when  found  in  persons  below  seventy  years  of  age;  and  yet 
nearly  one-third  the  total  number  of  persons  who  died  from  these 
two  causes  in  the  state  in  191G  were  betw^een  twenty  and  fifty,  and 
more  than  GO  per  cent,  of  them  were  under  seventy  years  of  age. 
Moreover,  the  increase  in  the  state  death  rate  from  all  causes 
between  1913  and  1916  was  only  4.5  per  cent.,  as  compared  with 
an  increase  of  10.5  per  cent,  from  organic  heart  disease.  This  dis- 
ease is  known  to  have  a  high  rate  among  lead,  iron  and  steel,  tobacco 
and  leather  workers,  of  whom  Pennsylvania  has  a  very  large  number. 

Both  because  of  their  own  injurious  effects  and  because  of  the 
encouragement  which  they  afford  to  the  growth  of  definite  occu])a- 
tional  diseases,  a  few  of  the  more  common  health  hazards  in  industry 
are  being  made  the  subject  of  investigation  and  attack  by  health 
departments  and  sanitarians.  One  of  these  is  the  problem  of  eye- 
strain, due  to  inadequate  illumination,  overwork  or  faulty  posture. 

"I  know  of  no  one  factor  that  affects  the  earning  capacity  of  the 
laboring  classes  to  such  an  extent  as  eye-strain."^ 


(i)Dr.   E.   E.   Alger,   in  an  address  before  the  Sooond  National  Conference  on   Industrial  diseases. 
Atlantic  City,   June.   1912. 


171 

"The  importance  of  adequate  lighting  in  industrial  establishments 
is  obvious,  as  a  matter  of  fact,  esjjecially  where  dangerous  processes 
are  carried  on,  as  bearing  on  health  in  many  ways,  directly  or  indi- 
rectly, and  as  a  condition  of  efficient  work.  On  the  health  side,  it« 
is  hardly  necessary  to  point  out  that  inefficient  illumination  entails 
risk,  strain  and  ultimate  danger  to  the  sight,  even  apart  from  inter- 
ference with  work,  that  it  tends  to  the  neglect  of  cleanliness  and 
adds  to  the  risk  of  working  in  poisonous  materials. 

"From  the  standpoint  of  health,  faulty  illumination  soon  exerts 
damaging  effects  upon  vision,  by  reason  of  varying  intensities  of 
light  which  produce  sharp  contrasts,  glares  and  shadows." 

"Sewing,  engraving  and  printing,  textile  work,  and  watch-making 
frequently  induce  excessive  strain  to  eyes.  Objects  close  by  are  seen 
only  by  muscular  effort.  The  constant  effort  to  maintain  distinct 
vision  causes  fatigue  of  the  muscles,  spasm  of  the  ciliary  muscle  and 
deficient  convergence,  from  which  result  headache,  defective  vision, 
nervous  exhaustion  and  various  neuroses.  Eventually,  under  these 
deleterious  influences,  the  eye  passes  into  a  condition  of  myopia  or 
chronic  nearsightedness,  which  is  a  distant  occupational  disease  due 
to  e,yestrain.  This  disease  runs  a  progressive  course,  the  vision  grad- 
ually fails,  the  eye  is  exceedingly  prone  to  acquire  all  kinds  of  inflam- 
mations, and  total  blindness  often  results,"^ 

Industrial  fatigue  is  another  danger  which  has  been  especially 
noticeable  in  the  war  industries  of  Pennsjdvania.  After  two  years 
experience  with  "speeding-up"  devices  and  over-time  work,  the 
British  Home.  Office  issued  in  August  1916  a  report  on  an  investi- 
gation of  industrial  fatigue  by  physiological  methods.  The  investi- 
gation covered  two  factories,  one  making  surgical  dressings  and  the 
other  an  engineering  works,  and  concludes: 

"Overtime  invariably  produces  the  lowest  output,  and  this  may 
be  traced  to  fatigue.  When  once  an  individual  has  through  labor 
during  ordinary  hours,  reached  a  certain  degree  of  fatigue,  and  pro- 
ceeds to  further  labor  (overtime)  without  taking  the  repose  nec- 
essary to  dissipate  the  fatigue  already  produced,  this  further  labor 
has  a  greater  physiological  effect  and  exhausts  the  organism  more 
than  would  a  similar  amount  of  labor  performed  when  fatigue  was 
absent.  This  is  a  well-known  fact  in  ph^^siology ;  it  is  also  a  matter 
of  ordinary  experience.  It  is  of  importance  in  the  present  connection 
because  it  indicates  that  overtime  labor  is  more  harmful  to  the 
worker  than  labor  performed  during  ordinary  liours.  It  is  ther*efore 
physiologically  extravagant." 

"Overtime,"  however,  is  not  the  only  cause  of  industrial  fatigue 
whicli  is  so  commonly  observed,  esi>ecially  among  boot  and  shoe, 
textile,  cannerr,  iron  and  steel,  tobacco  and  laundr-y  workers,  and 


(1) Monthly  Bulletin,  Pennsylvania  Department  of  IL^bor  and  Industry,  November,  1916,  pages  5-6. 


172 

which  is  the  result  of  laborious  work,  long  hours,  piece-work,  speed- 
ing up,  monotony,  constant  standing,  constant  strain,  chairs  or  stools 
without  backs,  faulty  postures,  jarring  processes,  pressing  or  holding 
•  objects  against  the  body,  eyestrain,  loud  noises,  irregular  hours  for 
sleep,  and  the  absence  of  work  variation  or  periods  of  relaxation 
and  recreation,  which,  in  the  case  of  women  workers,  means  also 
rest  rooms.  Such  fatigue  not  only  reduces  efficiency,  but  opens  the 
way  for  the  development  of  many  chronic,  degenerative  diseases, 
especially  among  women,  and  increases  the  hazard  of  industrial 
accidents.  "Fatigue  delays  work,  diminishes  output,  spoils  goods, 
causes  accidents  and  sickness,  keeps  workers  at  home,  and  in  all 
these  ways  is  an  obstacle  to  efficiency.  How  fatigue  can  'be  kept 
down  to  its  lowest  reasonable  limit,  how  the  working  power  of  the 
individual  can  be  maintained  from  day  to  day  and  from  week  to 
week  and  be  made  to  yield  a  maximum  output  without  detriment  Lo 
itself  and  to  others — constitutes  one  of  the  great  industrial  problems 
of  theday."(/) 

The  smoke-laden  atmosphere  in  which  thousand  of  emploj^ees  not 
only  work  but  live  is  believed  also  to  have  a  serious  etfect  upon  their 
health.     The  Mellon  institute  of  Industrial  Research  of  the  Univer-  * 
sity  of  Pittsburgh,  as  the  result  of  extensive  research  in  the  Pitts- 
burgh district,  states: 

"It  does  not  seem  an  exaggeration  to  say  that  more  persons  are 
devitalized,  disabled  and  poisoned  by  the  impurities  contained  in 
smoke-polluted  air,  than  by  the  noxious  ingredients  in  food  and 
water.  Not  only  do  the  solid  and  vaporous  ingredients  of  smoke- 
])egrimed  air,  the  noxious  compounds  of  carbon,  sulphur,  nitrogen, 
chlorine,  and  arsenic — irritate  the  sensitive  membranes  of  the  eyes, 
nose,  throat  and  lungs,  and  thus  aggravate  or  cause  inflammatoi'y 
diseases  of  these  organs  or  produce  collapse  of  their  sensitive  tis- 
sues, or  increase  their  susceptibility  to  such  specific  diseases  as 
bronchitis,  pneumonia  and  subacute  forms  of  phthisis;  but  the 
poisonous  compounds  also  enter  the  gastro-intestinal  tract  and  this 
causes  nausea,  vomiting,  diarrhea  and  systemic  poisoning. 

"In  Pittsburgh  a  recent  investigation  by  Dr.  W.  C.  White  shows 
that  pneumonia  increases  with  the  density  of  population  or  of 
poverty.  In  late  years  pneumonia  has  assumed  a  very  acute  and 
fatal  form  in  Pittsburgh. "^ 

Faulty  posture  and  strain  due  to  improperly  arranged  chairs, 
stools  or  machinery  may  be  responsible  for  serious  physical  harm 
to  the  worker.  The  Journal  of  the  American  Medical  Association 
contains  an  account  of  how  Dr.  Latta,  of  the  Pennsylvania  Railroad 
Relief  Association  found  that  a  surprisingly  large  number  of  loco- 


(MUnited   States   Public  Health   Reports,    Volnme   33,   No.    2,   January   11,    1918,   pajro   30. 
(2)  "Psychological  Aspect  of  the  Problem  of  AtmoRpheric  Smoke  Pollution" — J.  E.  Wallace  Wallin, 
Ph.   D.,    Director  of  Psychological   Clinic,    University  of  Pittsburgh. 


173 

motive  engineers  were  suffering  from  sciatica  of  the  right  leg,  due  to 
sitting  on  their  benches  sidewise,  with  the  weight  of  the  body  resting 
on  the  right  hip,  while  subjected  to  constant  jolting.  When  the  ends 
of  the  benches  were  cut  off  to  enable  the  men  to  sit  squarely  while 
facing  forward,  further  cases  ceased  to  develop.^  A  telephone 
Company  in  Philadelphia  had  constant  trouble  with  back-ache  among 
its  switchboard  operators  until  it  was  discovered  that  by  changing 
the  form  of  the  switchboards  the  injuriously  long  reaches  could  be 
eliminated.  Sedentary  workers  and  all  those  whose  work  involves 
repetition  and  close  application  are  particularly  exposed  to  this 
hazard. 

Sj)ecific  dangers  to  the  health  of  a  large  group  of  women  workers 
were  brought  out  in  an  investigation  made  during  the  summer  of 
1018  by  the  Women's  Committee  of  the  Council  of  National  Defense 
and  covering  100  factories  and  other  establishments  employing  about 
9,Q00  women  in  Pittsburgh.  Five  hotels  and  four  cigar  factories 
were  included  in  the  survey,  which  covered  also  a  large  number  of 
plants  engaged  in  the  manufacture  of  war  materials.  Women  were 
employed  at  a  wide  variety  of  operations,  including  office  work, 
elevator  operating,  riveting,  inspecting,  assembling,  operating  power- 
machines,  press  feeding,  wire  stitching,  etc.  The  wages  paid  for  the 
different  operations  were  recorded  in  144  instances,  and  over  70  per 
cent,  of  them  were  between  |5.00  and  |15.00  per  week.  While  this 
cannot  be  taken  as  an  exact  indication  of  the  proportion  of  employees 
to  be  found  in  this  wage  group,  the  number  of  women  employed  at 
the  more  skilled  and  more  highly  paid  types  of  work  did  not  exceed 
one-fourth  the  total  number.  In  only  two  instances  was  a  wage  of 
125.00  per  week  or  more  mentioned  and  to  thirty-three  different 
groups  of  women  less  than  flO.OO  per  week  was  paid. 

In  addition  to  data  on  the  general  sanitation  of  the  establishments 
visited,  special  facts  were  obtained  for  the  Commission  on  the  facili- 
ties for  the  protection  of  the  health  of  the  workers,  the  equipment 
for  the  treatment  of  the  sick,  and  the  extent  to  which  sick  benefit 
or  establishment  funds  were  being  maintained.  More  than  one-third 
of  the  places  of  employment  were  found  to  be  deficient  in  ventilation, 
light  or  general  cleanliness,  more  than  half  of  them  had  inadequate 
toilet  facilities,  and  over  two-thirds  had  no  rest  rooms.  Only  twelve 
establishments  had  hospitals  or  infirmaries,  thirty-five  had  first-aid 
equipment  only,  and  thirty-seven  had  made  no  provision  for  medical 
care  whatever. 

Conditions  in  hotels,  printing  establishments  and  cigar  factories 
were  particularly  bad,  and  in  twenty-three  cases  the  investigator 
advised  against  placing  women  with  the  concerns  visted.  In  one 
large  machine  shoj),  women  were  required  to  repeatedly  lift  weights 
of  forty  or  fift}^  pounds.     Twenty-five  pounds  is  set  as  the  maximum 


(^)"The  Occupational  Diseases,"  W.  G.  Thompson,  M.  D.,  page  548. 


174 

weight  which  women  should  he  required  to  repeatedly  lift,  by  the 
Women   in   Industry   Section  of  the   United   States  Department  of 
Labor.     In  another  plant,  a  foreman  testified  that  "the  labor  turn- 
over was  100  per  cent.    Men  and  women  were  sick  all  the  time,  due 
to  overwork  and  strain.    Much  of  the  work  that  was  not  heavy  was 
,  continuous,    affording    no    chance    to    rest    fatigued    or    untrained 
muscles."     In  one  hotel,  the  chamber  maids  were  constantly  ill  witli 
strained  and  aching  backs  because  too  few  girls  Av^ere  employed  to 
care  for  the  rooms.    The  housekeeper  in  this  place  had  been  dismissed 
just   prior   to   the   investigator's   visit,    because    she   comjilained    of 
immoral  conditions.     Dangers  to  morals  were  mentioned   in  every 
hotel   and  restaurant  visited.     In  a   number  of  establishments  tlic 
work  was  described  as  sufficiently  noisy   to  have  an  effect  on  hear 
ing.     In  one  factory  it  was  the  practice  of  the  women  to  lick  the 
labels  placed  on  large  numbers  of  products  every  day.     In  an  egg- 
candling  plant,  the  work  Avas  done  entirely  in  a  damp,  dark  cellar, 
and  the  manager  stated  that  men  employed  at  this  kind  of  work 
almost  invariably  drink  heavily. 

Few  of  the  dangers  to  health  mentioned  in  this  study  were  inherent 
in  the  nature  of  the  work  to  be  performed.  Most  of  them  could  be 
attributed  to  a  lack  of  knowledge  of  health  principles  on  the  part 
of  the  employer,  or  of  realization  that  the  health  of  his  employees 
bore  a  significant  relation  to  his  own  success. 

Several  investigations  made  by  the  Pennsylvania  Department  of 
Labor  and  Industry  reveal  health-hazards  due  to  conditions  of  work 
which  do  not  seem  necessary  to  the  carrying  on  of  the  particular 
I>rocesses  involved. 

During  the  summer  of  1918  the  Division  of  Industrial  Hygiene 
and  Engineering  made  a  study  of  the  seven  factories  in  the  State, 
engaged  in  making  felt  hats.^  The  chief  health-dangers  found 
there  were  tlie  presence  of  nitrate  of  mercury  particles  and  fumes 
in  the  air  of  the  carroting  rooms ;  particles  of  fur  and  dust  constantly 
flying  about  where  fur  was  being  sorted  and  cleaned  ;  and  steam  and 
vapor  in  the  sizing  and  dyeins^  rooms.  All  of  these  factors  are  dan- 
gerous in  varying  degrees  to  the  health  of  the  expose<l  workers,  and 
could  be  corrected,  in  the  opinion  of  the  inspectors,  by  installing 
proper  methods  of  ventilation,  swee])ing  and  cleaning.  In  several 
cases  the  floors  were  described  as  "filthy,"  and  in  some  instances 
lack  of  drainage  was  responsible  for  several  inches  of  water  in 
which  the  men  wore  obliged  to  stnnd  while  at  work.  "These  health 
liac'.irds  are  not  myths  *  *  *  several  of  our  largest  insurance 
companies  refuse  to  insure  fur  cutters  makers,  starters  and  sizers 
nt  anv  premium,  and  workers  in  other  depMrtmeuts  are  charged  an 
oxfr-a  henvy  premiuFi  on  ordinary  ]>oMcies."- 

rMTbP  vo^nits  of  this  Ptudy  woro  mado  availablo  to  the  Coinmission  by  Dr.  Francis  D.  Patter- 
son.   Chief  of  tbe  Division. 

r2)"S!Hnitarv  S+onrip-riss  fo'-  the  Felt  Hatting  Indnstry,"  Special  Report  by  New  Jersey  Depart- 
ment of  Labor,  1915,  page  45.  ^^_ 


176 

The  principal  investigation  of  health  in  relation  to  employment 
made  by  the  Department  in  recent  years  deals  with  two  groups  of 
tobacco  workers.  Those  employed  in  lliis  industry  in  the  state  in 
V.HA  numbered  37,000,  and  included  a  large  proportion  of  women. 
In  both  groups  studied  certain  physical  defects  due  to  occupation 
were  found.  The  first  investigation  made  in  1014  covered  111  fac- 
tories and  over  ;>'>,000  emi)loyees  in  Philadelphia,  Pittsbugh  and  else- 
where. 

In  most  of  the  factories  dirt,  tobacco  dust  and  poor  ventilation 
were  noticed.  Man}-  employees  were  under-nourished,  pale  and  stoop- 
shouldered.  Dirty  and  decayed  teeth  were  frequent.  At  least  a 
part  of  the  ''tendeiuy  to  ill  health"  was  ascribed  to  the  custom  of 
"biting  out''  the  ends  of  the  cigars  and  licking  the  wrappers.  But 
the  most  serious  menace  to  health  appeared  to  be  the  dust  and  waste 
which  covered  the  floors  and  was  stirred  by  "every  movement  of  the 
workers.-'  This  was  believed  to  be  the  source  of  the  excessive  death 
rate  from  tuberculosis  found  in  the  trade.  Comparativeh^  few  chil- 
dren uijder  sixteen  were  found,  but  these  were  in  bad  condition,  pale, 
stooped  and  overtired.  The  investigators  felt  that  these  younger 
employees  were  niost  susceptible  to  the  adverse  conditions  noted, 
and  that  the  employment  of  all  persons  under  sixteen  should  be 
forbidden. 

The  second  investigation,  made  in  1917  in  cooperation  with  the 
Universit}^  of  Pennsylviuiia  Clinic,  covered  a  smaller  number  of 
workers,  ninety-eight  males  and  o02  females  in  seven  factories,  but 
gave  somewhat  more  exact  information  on  the  relation  between  the 
occupation  and  the  diseased  conditions  found.  Congestion  of  the 
pharynx  and  of  the  lining  of  the  eyelid  were  abnormally  frequent, 
and  were  held  to  be  "at  least  in  some  measure  due  to  the  dust  and 
fumes  of  the  tobacco."  The  wearing  away  of  the  teeth  noticed  was 
caused  by  "biting  out"  the  ends  of  the  cigars,  the  gritty  material 
acting  like  emery  dust  on  the  teeth.  Other  disabilities  resulting 
from  the  occupation  were  a  large  amount  of  constipation',  caused  by 
lack  of  exercise  and  faulty  posture  while  at  work,  and  many  head- 
aches which  were  accounted  for  by  eye-strain  among  the  packers  and 
by  poor  ventilation  in  other  departments. 

The  most  complete  evidence  as  to  health  conditions  among  iron 
and  steel  workers  is  contained  in  a  study  made  in  1908  In'  Mr.  John 
A.  Fitch,  who  after  ten  months  of  intensive  investigation  in  the 
Pittr)>urgh  district,  felt  that  the  industry  contained  hazards  to 
ho:ilil!.  These  included  dust,  great  noise,  nervous  strain,  extreme 
h(  ;it,  and  the  twelve-hour  day.  A  fine  dust  is  always  present  in  the 
air  of  a  steel-mill,  which  steel  workers  declare  gives  rise  to  throat 
trouM^^s.  Due  to  the  noise  of  the  mills,  a  slight  deafness  is  common 
among  Ihe  employees.  The  noise,  the  vibration  of  the  machinery, 
12 


176 

tremendous  physical  strain  in  some  cases,  and  in  others  great  respon- 
sibility for  dangerous  machinery  combined  to  make  excessive  demands 
on  nervous  energy.  The  extreme  heat  in  which  many  men  were 
obliged  to  work  was  also  considered  a  special  health  hazard,  while 
the  twelve-hour  day,  Mr.  Fitch  believed,  intensified  all  the  other 
hazards  and  made  the  men  "chronically  tired." 

It  is  worthy  of  note  that  the  standard  American  text  on  industrial 
liygiene'  devotes  a  chapter  to  the  iron  and  steel  industry  among 
the  "occupations  involving  exposure  to  conditions  injurious  to 
health."  Sir  Thomas  Oliver,  the  English  authority  on  industrial 
hygiene,  reports  that  English  iron  and  steel  workers,  though  the 
eight-hour  day  is  much  more  common  there  than  in  the  United 
States,  have  a  death-rate  37  per  cent,  above  the  standard  for  occu- 
pied males. 

COA.L  MINING  IN  PENNSYLVANIA. 

Pennsylvania  produces  practically  all  the  anthracite  and  by  far 
the  largest  portion  of  the  bituminous  coal  mined  in  the  United  States 
and  employs  one-third  the  coal  miners  of  the  country.  The  number 
of  employees  in  and  about  the  mines  in  1916  was  333,473  and  the 
total  coal  produced  amounted  to  256,804,012  tons.  Because  of  the 
tremendous  part  which  coal  mining  plays  in  the  industrial  life  of  the 
state,  it  was  decided  to  devote  special  attention  to  its  effect  on 
health. 

Health  hazards  involved  in  coal  mining  are  briefly  discussed  in 
Dr.  Hamilton's  study,  special  emphasis  being  laid  on  the  high-death 
rate  among  miners  from  non-tuberculous  diseases  of  the  lungs.  This 
fact  is  confirmed  by  the  results  of  the  Western  Pennsylvania  Survey, 
which,  besides  finding  that  the  total  sickness  rate  among  miners 
was  eight  per  cent,  higher  than  the  general  rate  for  white  adult 
males,  states  that  "It  is  probable  that  the  true  rate  for  miners' 
asthma  involving  disability  for  work  is  not  less  than  400  per  100,000 
exposed  among  anthracite  and  not  less  than  175  per  100,000  among 
bituminous  miners.  These  figures  for  anthracite  and  for  bituminous 
miners  measure  within  certain  limits  of  error,  the  incidence  of 
anthracosis  among  the  coal  miners  in  the  two  groups,  asthma  being 
the  most  prominent  symptom,  to  the  lay  mind  at  least,  of  that  con- 
dition."2 

Special  permission  was  obtained  from  Dr.  Emery  R.  Hayhurst, 
of  the  Ohio  State  Board  of  Health  to  quote  from  a  study  of  health 
dangers  among  coal  miners  in  Illinois  which  he  made  for  the 
Illinois  Health  Insurance  Commission  during  the  summer  of  19J8. 
Extracts  from  this  report  follow,  and  show  to  a  certain  extent  condi- 
tions in  Pennsylvania  coal  mines: 

(i)Koher   and   Hanson's    "Diseases    of   Oooupation    and    Vocational    Hygiene." 

(2) Sickness  Survey  of  Principal  Cities  in  Pennsylvania  and  West  Virginia,   page   53. 


177 

THE  CONDITIONS  UNDER  WHICH  MINERS  WORK. 

"Coal  Seams. — For  convenience,  coal  seams,  in  mining  parlance, 
are  numbered  upward  from  No.  1,  or  that  at  the  lowest  level  (and 
therefore  the  earliest  geologically)  to  that  which  constitutes  the  most 
recent  deposit.  Hence  many  seams  are  present  in  most  districts, 
superimposed  one  above  the  other,  often  with  hundreds  of  feet  of 
rock  strata  separating  them;  but,  because  of  upheavals,  glacial  ac- 
tion, erosions,  etc.,  even  the  deepest  seam,  No.  1,  may  lie  at  the  sur- 
face (or  indeed  be  'in  the  sky' — when  there  is,  therefore,  no  coal  to 
be  found  in  that  place).  From  a  health  point  of  view  the  particular 
seam  has  some  significance  as  to  whether  (1)  it  is  'low  coal,'  thereby 
necessitating  a  great  deal  of  kneeling  at  work;  (2)  whether  it  con- 
tains much  sulphur  and  other  impurities,  especially  tending  to  'dust ;' 
(3)  wiiether  the  strata  next  above  and  below  the  coal  are  dust  pro- 
ducting,  and  (4)  w^hether  mine  gases  are  apt  to  be  encountered.  The 
same  seam  in  different  localities  often  varies,  however,  in  these 
factors.  In  but  a  few  instances  in  the  state  is  more  than  one  seam 
worked  at  a  single  mine.  Working  two  seams  means  working  at  two 
or  more  levels,  unless  seams  are  very  close  together. 

"The  work  of  the  miner  has  gradually  changed,  through  the  in- 
troduction of  machines  and  the  use  of  powder,  from  that  of  pick 
work  on  the  solid  face  of  coal  to  that  of  breaking  up  large  chunks 
of  coal  and  loading  them  into  the  mine  cars.  Hence,  workers  'at 
the  face'  have  come  to  be  called  'miners,'  'machine  men,'  'loaders,' 
'shot-firers,'  etc.,  according  to  the  nature  of  their  duties.  This  is 
important. to  note  since  it  means  that  many  of  the  afflictions  prev 
iously  attributed  to  'miners'  have  become  relatively  scarce  or  are  no 
longer  existent  because  of  these  changes  in  work  methods. 

"Blasting  Substances. — Throughout  the  entire  mining  field,  with 
the  exception  of  long-wall  mining,  black  powder  is  the  explosive 
used. 

"The  time  of  use  of  blasting  substances  may  constitute  a  serious 
menace  to  the  health  of  coal  miners.  The  principal  point  is  whether 
'shooting'  is  done  during  work  hours  so  that  the  powder  fumes  and 
smoke  are  present  during  work  hours. 

"Mine  Gases. — The  gases  encountered  in  coal  mines  are  of  three 
types — 'natural'  gas  or  methane,  black  damp  or  carbon  dioxide,  and 
white  damp  or  carbon  monoxide.  Very  exceptionally,  hydrogen  sul- 
phide may  be  detected  from  old  timbers,  gob  pile  refuse  and  animal 
deposits. 

"Of  these  three  gases  the  one  which  the  miner  fears  the  most  is 
methane  (marsh  gas,  CH4)  because  it  is  so  easily  exploded  when 
lights  come  in  contact  with  it.  Methane  gas  is  practically  half  the 
weight  of  air  and  hence  tends  to  accumulate  about  the  roof.  It  is 
especially  to  be  feared  in  dry  mines  and  in  the  vicinity  of  faults  in 
the  coal  seam.  Certain  coal  strata  or  seams  are  well  known  to  be 
associated  with  it.  For  our  purpose,  however,  it  may  be  dismissed 
as  it  has  a  very  limited,  if  any,  influence  upon  health,  at  least  in  the 
amounts  to  which  it  accumulates  in  mines.  It  is  the  most  common 
gas  encountered  in  mines  and  is  called  'natural  gas'  because  it  oc- 
curs naturally,  i.  e.,  comes  out  of  the  coal  and  rock  strata.  It  is 
identified  by  the  miner  with  his  naked  (carbide)  lamp,  which  it 
causes  to  flame  up  brighter  than  usual  and  perhaps  to  pop  in  min- 


178 

atnre  explosions  (the  lighting  of  small  pockets  of  gas).  When  seek- 
ing for  minute  traces  of  it  the  miner  holds  his  lamp  along  the  pockets 
in  the  roof.  It  lias  neither  odor  nor  any  sensible  effect  upon  the 
liuman  being. 

"Black  damp,  or  carbon  dioxide,  does  not  occur  naturally  in  mines 
as  a  rule.  There  are  some  evidences  that  carbonaceous  rock  may 
disintegrate  to  an  extent  great  enough  to  produce  the  gas,  par- 
ticularly if  it  is  associated  with  sulphurous  waters.  In  old  mines, 
as  in  any  deep  pits,  it  accumulates  because  of  the  lack  of  ventilation 
and  the  tendency  of  this  heavy  gas  to  seek  low  levels.  In  poorly 
ventilated  mines  it  accumulates  to  an  extent  to  be  noticeable  upon 
the  respiration,  and  more  especially  in  the  case  of  certain  individuals 
suffering  from  acidosis  from  any  cause  (heart,  kidney,  or  arterial 
diseases  in  particular).  This  gas  is  nearly  half  again  the  weigM 
of  air  and  accumulates,  at  first,  along  the  floor  of  entryways  and 
rooms.  Its  usual  origin  in  mines  is  from  old  workings  which  have 
been  shut  off  from  the  general  ventilation  scheme  of  the  mine  but 
in  which  the  battices  or  stopjjings  are  leaky  and  the  gas  comes  up 
through  the  nooks  and  crevices  of  its  own  pressure.  It  is  also  espe- 
cially to  be  feared  in  the  case  of  mine  fires,  because  the  regular 
ventilation  does  not  remove  the  products  of  combustion  fast  enough 
It  is  the  typical  asphyxiating  gas  and  usually  gives  plenty  of  Avarning 
that  it  is  accumulating,  in  the  way  of  increased  breathing,  easy 
fatigue,  headache  and  a  heightened  or  dusky  color  of  the  face.  It 
affects  the  ndner's  lamps,  causing  them  to  smoke  and  the  flame  to 
become  rather  bluish.  It  readily  affects  bird  life,  so  that  the  canary 
h:  sometimes  used  in  its  detection.  Should  anything  happen  to  the 
ventilating  fan  or  other  ventilation  apparatus,  it  accumulates 
rapidly  in  the  mine,  and  necessitates  withdrawal  of  the  miners  at 
once.  When  necessary  to  enter  strata  of  this  gas,  helmets  with 
oxygen  tanks  are  used. 

"White  damp,  or  carbon  monoxide,  is  of  very  rare  occurrence  in 
mines  and  is  always  an  accidental  affair.  It  occurs  principally  from 
Incomplete  combustion  of  powder  explosions,  when  it  may  pervade 
a  considerable  area  of  the  mine  before  it  is  thinned  out  by  the  forced 
ventilation.  It  also  occurs  in  the  case  of  fires,  through  incomplete 
combustion,  and  may  leak  into  workings  from  fires  which  are  sealed 
off  in  sections  of  the  mine.  Carbon  monoxide  is  a  gas  slightly  lighter 
than  the  air  and,  therefore,  tends  to  accumulate  in  the  upper  half 
of  the  stratum  of  air,  although  it  is  quite  evenly  distributed^  if  there 
is  much  moving  to  and  fro,  or  agitation  of  the  air  by  mine  car 
trains.  It  is  called  'white  damp'  apparently  for  two  reasons:  One, 
because  it  causes  the  flame  of  the  miner's  lamp  to  burn  up  more 
brightly,  and  secondly,  because  it  is  usually  associated  with  a  fine 
vaiK)r,  the  remnants  perhaps  of  powder  smoke.  In  mines  where 
shooting  is  done  in  work  hours  it  often  produce*  its  characteristic 
symptoms  which  the  miners  call  the  'thumps,'  due  to  the  type  of 
headache  experienced.  Cases  of  acute  poisonings  leading  to  death 
rarely  occur  among  miners.  It  is  probable  that  chronic  or  low  grade 
poisonings  are  frequent  where  shooting  is  allowed  during  work 
hours. 

"The  hygienist  has  but  to  witness  the  operation  of  gasoline  motors 
in  a  mine  either  at  the  bottom  of  the  hoisting  shaft  or  in  the  main 
entries,   to  l)ecome  suspicious  of  their  eft'ects  upon   the  mine  air, 


179 

particularly  at  the  bottom  where  a  certain  small  percentage  of 
miners  must  work  all  day.  Motors  running  overly  rich  and  discharg- 
ing smoke  and  very  perceptible  gasoline  exhaust  fumes,  were  wit- 
nessed. There  was  no  reason  to  be  surprised  at  complaints  of 
miners  in  regard  to  these  features.  It  is  probably  but  a  question  of 
time  before  all  gasoline  motors  will  be  done  away  with  in  the  few 
mines  in  which  they  are  now  found.  Tlie  question  of  investment 
»eems  to  be  the  chief  reason  for  their  continuance  at  the  present 
time.  The  liklihood  of  carbon  monoxide  and  other  exhaust  fumes, 
which  in  degrees  of  poisoning  may  amount  to  anything  from  the 
sudden  acute  cases  to  the  sIoav  chronic  effects,  are  the  chief  dangers. 
Furthermore,  smoke  from  defective  motors  is  often  so  pronounced 
as  to  obstruct  vision  and  noise  is  so  loud,  in  the  absence  of  mufflers, 
as  to  interfere  with  signals  and  perhaps  cause  some  permanent  inter- 
ference with  hearing  from  the  reverberations  which  take  place  in  the 
entryways.  In  the  mines  where  they  are  used,  the  hoisting  shaft 
constitutes  the  'upcast'  for  the  air  current.  Hence  these  motor  fumes 
do  not  atfect  the  workers  at  the  face  but  they  travel  with  the  air 
current  from  the  face  to  the  foot  of  the  hoisting  shaft,  always  in- 
creasing in  concentration,  also  in  velocity  of  movement.  Hence  the 
workers  who  run  the  cars  on  and  off  the  cages  are  the  ones  chiefly 
affected  by  the  fumes. 

^'Temperature. — The  temperature  of  a  coal  mine  is  quite  constant 
throughout  all  seasons  of  the  year,  usually  varying  not  more  than 
ten  degrees  after  proceeding  a  few  hundred  feet  from  the  foot  of  a 
shaft.  Even  at  the  foot  of  the  downcast  the  air  brought  in  on  a 
hot  day  is  generally  reduced  in  temperature  through  its  passage 
down  the  wet  and  dripping  shaft.  After  the  air  has  traveled  a  few 
hundred  feet  it  has  gained  the  'temperature  of  the  mine,'  which  it 
holds  more  or  less  constantly  until  it  is  returned  to  the  upcast  and 
out.  Within  the  mine  a  number  of  factors  tend  to  increase  the 
tewiperature  somewhat,  such  as  the  heat  coming  from  the  miners' 
bodies,  from  the  aninmls,  from  the  motor  cars,  from  shooting,  from 
the  decomi)osition  of  timbers,  etc. 

''The  temperature  of  mines  vary,  however,  according  to  their 
depth.  As  a  rule  shallow  mines  are  the  coolest,  due  to  the  fact  that 
they  are  usually  wet  mines,  which,  in  turn,  is  due  to  their  proximity 
to  the  ground  waters  which  leak  into  them.  In  Illinois  such  mines 
run  from  fifty  to  sixty  degrees  in  temperature.  Mines  which  are 
from  300  to  600  feet  deep  have  temperatures  ranging  from  sixty  to 
seventy  degrees.  Mines  from  600  to  1,000  feet  deep  have  tempera- 
tures which  range  from  seventy  to  eighty  degrees.  Men  working  in 
the  deeper  mines  often  strip  to  the  waist  because  of  the  effects  of 
this  higher  temperature. 

^'Miners,  therefore,  as  a  group  work  under  more  admirable  temper- 
ature conditions  than  practically  any  other  class  of  workmen.  ^  In 
the  hot  seasons  of  the  year  they  have  a  temperature  which  is  cool, 
exhilarating  and  energizing  and  admirably  adapted  for  the  heavy 
work  involved.  In  the  frigid  seasons  their  quarters  are  relatively 
nice  and  warm.  When  air-circulation  is  also  satisfactory,  ventila- 
tion conditions  approach  the  ideal,  except  for  one  element,  dust. 

"Humidity. — The  amount  of  water  vapor  in  the  air  of  cool  mines 
varies  directly  according  to  the  wet  or  dry  condition  of  the  mine. 
x\bout  the  shafts  it  is  probably  near  the  point  of  saturation.     Since 


180 

evaporation  is  excessive  at  these  points,  however,  the  temperature 
is  kept  low  and  the  total  condition  is  therefore  good  for  the  type  of 
active  work  performed.  Within  the  interior  of  dry  mines  the 
dehydrating  properties  of  the  dry  coal  and  coal  dust  are  such  as  to 
render  the  air  excessively  dry.  Dry  air,  itself,  is  irritating  to  the 
skin  and  mucous  membranes  and  when  combined  with  dust  is  apt 
to  become  much  more  so.  This  latter  will  depend  upon  whether 
activity  is  great  enough  to  produce  plenty  of  perspiration  and 
secretion. 

^^Dust. — Because  of  the  darkness  and  the  lack  of  reflecting  sur- 
faces, one  is  easily  misled  as  to  the  quanitity  of  dust  in  the  working 
atmosphere  of  a  coal  mine.  In  fact,  one,  at  first,  has  the  impression 
that  there  is  very  little.  But,  except  where  the  coal  dust  is  wet 
when  mined,  and  this  is  very  rarely  the  case,  dust  is  present  in  large 
amounts,  particularly  in  the  work  rooms,  and  about  mining  machines 
and  also  in  the  entries  where  rapidly  moving  mine  trains  keep  it 
in  the  air.  Naturally,  in  damp  and  dripping  mines  dust  will  be 
much  reduced,  but  such  conditions  are  usually  limited  to  the  pas- 
sage ways  rather  than  to  the  work  rooms.  Where  mines  are  char- 
acterized by  the  dry^  type  of  work  room,  the  chief  defect  in  the  work- 
ing atmosphere  is  not  a  chemical  one  (of  the  amount  of  oxygen  and 
carbon  dioxide,  or  one  of  temperature  extremes)  but  is  this  purely 
physical  one  of  an  excessive  amount  of  dust  particles. 

"Where  the  rock,  clay  or  earthy  matter  which  occurs  in  connec- 
tion with  mining  coal  does  not  pulverize,  it  is  of  little  health 
significance.  Where,  however,  it  tends  to  dust,  its  harmful  char- 
acteristics are  to  be  regarded  as  in  proportion  to  its  hardness  or 
gritty  character.  For  instance,  sandstone  and  flint  dusts  are  con- 
sidered much  more  harmful  than  clay  or  soapstone  dusts.  Where 
irritating  sulphur  dusts  occur  with  any  frequency,  this  is  to  be  con- 
sidered, probably,  the  worst  dust.  Of  the  dangerous  dusts  in  con- 
nection with  coal  mining,  their  harmful  nature  may  be  stated  ^in 
descending  order  as  follows:  coal,  clay,  soapstone,  shale,  slate,  sand- 
stone, granite  and  sulphur. 

"Absenteeism. — Absences  from  all  causes  were  at  ten  i)er  cent,  each 
day  throughout  the  coal  fields  as  a  whole,  with  this  percentage  about 
doubled  for  a  day  or  two  following  paydays,  which  occurred  twice 
per  month. 

"An  inquiry  at  the  mines  as  to  how  much  of  the  absenteeism  was 
due  to  sickness  failed  to  reveal  any  definite  information.  The  usual 
replies  were  that  ^there  is  no  way  of  finding  out;'  ^they  just  want  a 
day  off ;'  'most  of  the  absences  are  due  to  drunkenness ;'  'no  records 
are  kep't  nor  has  a  practical  way  been  devised  for  keeping  such.' 
Certain  large  corporations  were,  however,  beginning  a  study  of  this 
subject. 

SUMMARY   OF   HEALTH   HAZARDS   IN   MINES. 

"For  the  principal  operations  in  mines,  the  following  may  be  given 
as  a  summary  of  the  chief  health  hazards: 

"Cagers. — These  men  push  the  cars  on  and  off  the  hoising  shaft. 
They  are  doing  active  work.  Those  at  the  bottom  are  in  a  strong 
draft  of  moving  air,  since  the  hoisting  shaft  is  usually  the  upcast  for 
the  air  leaving  the  mine.  Hence  the  entire  mine  air  which  is  col- 
lected by  the  return  entries  constitutes  their  Avorking  and  breathing 
atmosphere.     It  contains  a  certain  amount  of  fine  dust,  practically 


181 

imperceptible  to  the  naked  eye,  which  is  the  result  of  the  activities 
within.  Where  the  air  contains  smoke  or  gasoline  motor  fumes,  these 
workers  are  especially  concerned.  Their  work  is  laborious  but,  for 
selected  men,  not  overly  hazardous.  They  usually  have  little  time 
for  sitting  around,  so  that  the  cool,  damp,  rapidly  moving  air  should 
be  no  hazard.  Those  men  who  work  in  the  tipples  at  the  top  of  the 
hoisting  shaft  are  usually  within  buildings  partially  protected  from 
the  weather  and  high  up  in  the  air,  where,  however,  the  air  within 
is  loaded  with  coal  dust  or  whatever  dirt  is  brought  out  of  the  mine. 
A  considerable  number  of  laborers  are  employed  about  the  foot  of 
the  hoisting  shaft  and  the  tipple,  where  they  have  the  same  hazards 
as  just  described. 

"Drivers. — Using  this  term  to  include  motormen,  trip-riders  and 
mule-drivers,  we  tind  here  processes  concerned  with  more  or  less 
rapid  transit  through  entryways,  usually  in  strong  drafts,  and  a 
considerable  amount  of  dust  produced  from  the  coal  carried  and 
from  the  surroundings  where  these  are  not  moist  or  wet.  In  addi- 
tion, long  rides  seated  on  cars  constitute  a  hazard  for  many.  Con- 
sequently, the  effects  of  cool,  damp  drafts  have  opportunity  to  be 
considerable.    Boys  or  youths  usually  make  up  this  class. 

"Laborers. — Laborers  are  scattered  about  more  or  less  all  over 
the  mine,  depending  upon  the  type  of  mine  and  the  character  of 
work.  Their  hazards  are  the  same  as  those  of  the  workers  in  whose 
vicinities  they  are,  except  that  they  are  more  apt  to  be  changing 
from  place  to  place;  consequently,  health  hazards  are  less  in  dura- 
tion, although  more  in  number. 

"Loaders. — Loaders  Avork  in  the  rooms,  breaking  up  the  coal  and 
loading  it  into  mine  cars  after  machines  and  shootings  have  dis- 
lodged it  from  the  face.  They  are  subject  to  the  total  dust  hazards 
of  the  mine,  principally  coal  dust.  Also,  to  the  full  extent  of  any 
bad  ventilation  or  accumulation  of  black  damp  which  may  occur. 
Their  work  is  laborious,  all  piece-work  type  and  rather  monotonous. 
They,  however,  have  the  advantage  of  considerable  change  in  posture. 
When  work  is  slack,  or  empty  cars  do  not  come  frequently  enough 
they  are  apt  to  sit  around  in  cool  damp  places  and  thus  expose  them- 
selves. 

"Machine  Men. — Probably  the  dustiest  job  in  the  mine  is  that 
carried  on  by  the  machine  men.  One  of  them  is  employed  most 
of  the  time  in  shoveling  back  the  fine  dust  (bug  dust)  created  by  the 
machine  which  is  undercutting  the  coal  seam  and,  many  times, 
scouring  the  clay  bottom  or  other  substances  beneath  the  seam.  The 
shoveler  works  with  his  face  about  two  feet  from  the  dust  heap  and 
his  exposure  is  inordinate.  However,  the  other  men  in  and  about 
machines  have  but  little  less  exposure,  since  the  air  of  the  work  space 
is  heavy  with  dust.  Machine  men  are  usually  big,  powerfully  built  in- 
dividuals. About  every  t«n  to  twenty  minutes  they  are  concerned  in 
moving  the  machine  along,  which  is  very  laborious  and  straining 
work.  As  with  all  men  at  the  face,  they  have  the  same  atmospheric 
hazards  so  far  as  ventilation  is  concerned. 

"Miners. — In  old  days  coal  was  mined  directly  off  the  face  by  pick, 
sledge,  wedge  and  drill.  With  the  introduction  of  powder,  much  of 
this  slow,  hard  work  disappeared.  Miners  are  employed  where  ma- 
chines are  absent.  After  shooting  down  the  coal  more  or  less  per- 
fectly, they  break  it  up  with  picks  and  sledges  and  load  it  into  cars. 


182 

The  dust  hazard  for  them  is  great  and  naturally  is  worse  where  other 
substances  than  pure  coal  are  encountered  in  the  course  of  their 
wbrk.  They  have  the  same  ventilation  hazards  as  for  all  workers  at 
the  face.  While  their  work  is  laborious,  and  all  piece-work  and 
rather  monotonous,  with  considerable  jar  and  vibrations  from  tools 
used,  there  is  the  advantage  of  a  standard  work  day  of  eight  hours 
which  they  very  rarely  ever  exceed.  Throughout  the  entire  coal 
mining  district  the  eight-hour  day  prevails  and  covers  the  vast 
majority  of  workers.  Occasionally  'spurt'  work  prevails  for  both 
loaders  and  miners  and  others  at  the  face.  Here  there  is  a  shortage 
of  mine  cars  and  when  a  car  is  obtained,. the  man  or  men  concerned 
work  strenuously  for  twenty  minutes  or  so  in  filling  in,  then  wait 
for  the  next  'empty'  to  come  along.  In  most  mines  there  is  enough 
'dead  work'  to  keep  them  occupied  in  the  interval,  which  may  last 
upwards  of  a  half-hour  or  so.  In  many  instances,  however,  they  sit 
around  in  the  cool  atmosphere  with  sweat-soaked  clothing  and  per- 
haps lunch  a  bit  from  their  buckets.  Undue  exposures  and  liability 
to  chilling  naturally  occur. 

"Shot-Firers. — In  bigger  mines  a  few  men  are  employed  toward 
the  quitting  hour  of  the  day  to  shoot  down  the  coal  for  the  next  day'?: 
work.  The  powder  or  shot  has  usually  been  placed  for  them  with 
fuse  attached,  so  that  their  duty  consists  of  shooting  off  the  'shoots.' 
They  are  employed  for  a  couj)le  of  hours  and  their  chief  hazard  is 
^s  ork  in  powder  smoke  and  incompletely  combusted  powder  gases 
which  fill  the  sections  of  the  mine  during  this  procedure.  They 
usually  go  from  place  to  place  in  a  logical  order  calculated  to  keep 
them  in  the  freshest  air,  but  the  force  of  the  exposions  disarranges 
the  ventilation  to  some  extent  during  this  process.  Breathing  of 
white  damp  (CO)  as  well  as  black  damp  (C02)  constitutes  their 
chief  liealth  hazard.    Dust  is  naturally  a  bad  feature  also. 

"Thnbermen. — These  workers  are  employed  mostly  at  the  breast 
of  the  mine  in  and  about  the  rooms  and  the  terminal  entries,  and 
have  dust  and  ventilation  hazards  as  their  chief  concern.  Wet  road- 
ways and  other  places  involve  them  probably  more  than  others  in 
the  mine. 

"Trappers. — Trappers  are  usiuilly  boys  or  youths,  sometimes  old 
men,  who  stay,  at  switch  junctions  or  at  doors  and  save  the  time  of 
mine  train  drivers  or  motormen  by  operating  switches  or  opening 
doors.  They  usually  have  a  manhole  or  niche  in  the  wall  where  they 
may  sit  between  activities.  A  bench  is  almost  always  provided  for 
them.  They  are  naturally  in  good  draft,  breathe  the  entryway  dusts 
and,  because  of  long  workless  intervals,  are  subject  to  the  hazard 
of  chilling.  There  is  often  some  strain  in  connection  with  their 
Avork  as  wlien  assisting  m  the  steering  of  cars  across  rough  and  un- 
certain switches. 

"Tipple  Men. — The  chief  hazards  of  the  workmen  in  the  coal 
tipple  are  the  breathing  of  an  excessive  amount  of  dust,  mostly  coal 
dust,  which  arises  in  connection  with  the  dumping  and  screening 
and,  perhaps,  crushing  of  coal  in  the  vicinity.  While  more  or  less 
within  doors,  tipples  are  usually  not  protected  much  against  the  low 
temperatures  of  winter,  and  being  high  in  the  air,  are  cold 
places  to  work.  The  weighmen  are  usually  located  in  a  part  of  the 
tipple  more  or  less  partitioned  oft*  and  nearly  always  provided  with 


183 

some  form  of  heating  appliance  in  tlie  winter  time.  There  are  al- 
ways two  of  them,  except  in  the  smallest  mines,  one  of  whom  is  the 
company  weigliman  and  the  other  the  check  weighman  who  rep- 
resents the  miners. 

"Track  Men. — Track  men  move,  or  assist  in  moving,  the  railroad 
cars  slowly  along  as  the  coal  chutes  fill  them.  Their  work  is  very 
dusty  and  they  have  full  weather  exposure.  They  assist  somewhat^^ 
also,  in  shoving  the  lumps  of  coal  about  when  they  tend  to  flow 
over  the  top  of  the  cars.     Some  of  them,  also,  keep  the  ground  clean. 

"Hoisting  Engineers, — Where  steam  hoists  are  used,  investigations 
of  engine  roomif^howed  that  the  hoisting  engineer  often  worked 
under  an  unusual  temperature  exposure  (110  to  140F.).  While 
buihlings  for  hoisting-engines  varied  at  dilt'erent  mines,  the  engineer 
was  usually  placed  between  two  steam  engines  with  steam  pipes  un- 
der foot  and  perhaps  overhead.  To  a  large  extent,  windows  were 
depended  upon  for  ventilation.  Of  all  the  men  at  the  mine,  he  is 
the  one  required  to  be  the  most  mentally  alert,  since  he  must  be 
constantly  watching  the  indicators  on  the  dials  to  keep  informed  of 
the  height  and  speed  of  the  rapidly  moving  cages  loaded  with  coal 
or  men,  which  cages  he  controls  with  his  liand-levers.  He  must  also 
be  mindful  of  whistle  or  bell  signals  by  which  he  starts  his  level's. 

''('oal  Washers. — ^In  tlie  present  great  demand  for  coal,  coal  wash- 
ers have  largely  been  allowed  to  stand  idle.  However,  at  a  con- 
siderable nund)er  of  mines  this  process  is  still  carried  on  and  re- 
quires tlie  presence  of  some  ten  to  twenty  men.  As  the  term  implies, 
the  screened  coal  is  washed  with  water,  which  frees  it  from  much 
impurity,  particularly  of  sulphur  deposits  and  the  finer  dusts.  The 
atmosphere  about  all  coal  washers  is  exceedingly  dusty,  due,  princi- 
pally, to  the  crashing  process  preceding  the  washing.  While  the 
process  is  within  enclosures,  there  is  no  special  protection  from  cold 
weather.  The  men  have  frequent  periods  of  inactivity,  and  are, 
therefore,  liable  to  chilling.     Noise  is  also  a  marked  feature. 

"Housing  Conditions. — The  hygiene  and  sanitation  of  housing  is 
important  since  it  involves  about  one-third  of  the  normal  day  for 
the  worker  aiid  most  of  the  time  for  his  family.  The  typical  mine 
town  consists  of  rows  of  dingy  houses,  all  built  after  one  or  two  pat- 
terns, often  located  on  hillsides,  with  rows  of  privies  located  close  to 
wells  or  draining  toward  the  wells  on  the  next  street.  Rarely  any 
attempt  at  garbage  collection  exists.  Often  small  ditches  of  water 
act  as  open  sewers.  Screens  for  the  houses  are  usually  provided  by 
the  occupant  if  present  at  all.  Many  nuning  towns  are  unincorpo- 
rated. There,  is  often  no  local  health  officer.  The  board  of  health  con- 
sists of  the  nmyor  and  two  or  more  members  of  the  council  in  the 
larger  towns.  In  some  places  only  the  township  supervisor  arrange- 
ment prevails.  Very  often  the  health  officer  is  not  a  physician  and 
is  entirely  unskilled  in  matters  of  hygiene  and  sanitation.  Very 
often  he  belongs  to  the  old  type  of  health  officer,  who  lays  great 
stress  on  garbage  collection  and  ashes,  and  pays  little  attention  to 
wells,  outhouses,  screening  or  milk   supply." 

According  to  the  report  of  the  Pennsylvania  Department  of  Mines 
for  1916,  "the  mines  of  Illinois  and  Ohio  cannot  be  compared  with 
those  of  Pennsylvania  for  gas  and  dust."  "During  the  past  nineteen 
years  the  worst  accidents  have  been  due  to  gas  and  dust  and  could 
have  been  prevented  by  proper  operation  of  the  mines."     In  1916, 


184 

these  two  causes  accounted  for  8.74  per  cent  of  the  fatal  accidents  in 
bituminous  mines  and  8.65  per  cent,  of  those  in  anthracite  mines. 
''Mining  is  now  more  difficult  and  hazardous  than  ever  before.  The 
miners  are  no  longer  the  early  type  of  trained  British  workers,  but 
are  largely  agricultural  laborers  from  Southern  Europe,  and  re- 
cently negroes  from  the  South  are  migrating  to  the  Pittsburg  dis- 
trict in  large  numbers."  "Moreover,  housing  conditions  are  generally 
poor.  Little  has  been  done  to  improve  the  houses  built  years  ago, 
which  in  many  cases  are  now  most  inconvenient  and  unsanitary. 

"Greater  attention  is  given  to  approved  methods  of  mining,  safety 
appliances,  sanitary  conditions  and  the  general  welfare  of  the  miner 
while  at  work,  but  not  so  much  to  the  home  or  .social  life  of  the 
community."^ 

Inquiries  were  made  by  the  Commission  of  physicians  practising 
in  the  anthracite  and  bituminous  regions  and  of  representative  em- 
ployers, to  ascertain  as  far  as  possible  general  health  conditions 
among  miners  and  their  families.  The  evidence  gathered  supports 
the  findings  of  the  Western  Pennsylvania  Survey.  While  the  miners 
themselves  do  not  seem  to  be  a  particularly  unhealthy  class  of  men, 
the  high  rate  of  non-tuberculous  respiratory  diseases  among  them 
probably  raises  their  sickness  rate  slightly  above  that  of  the  rest 
of  the  community.  Among  1,208  families  included  in  the  report  of 
the  Mothers'  Assistance  Fund  for  1916,  the  death  of  the  principal 
wage  earner  in  286  cases  had  been  due  to  his  occupation;  although 
only  19  per  cent  of  the  total  number  of  men  had  been  miners,  min- 
ing was  responsible  for  45  per  cent  of  the  deaths  which  were  at- 
tributed to  occupation.  In  a  study  of  110  families  made  for  the 
Commission  by  the  Mothers'  Assistance  Fund  in  1918,  it  was  found 
that  91  per  cent  of  the  men  were  under  forty  years  of  age  at  the  time 
of  death,  and  that  among  seventy-three  men  who  died  in  Lackawanna 
county,  twenty-one  had  pneumonia,  nine  had  tuberculosis,  and  ten 
were  victims  of  industrial  accidents. 

Inquiry  into  conditions  in  the  families  of  miners  tells  a  far  more 
striking  story.  Practically  every  physician  consulted  stated  that  the 
sickness  rate,  especially  among  children,  was  noticeably  higher  than 
among  other  families  in  the  community.  As  it  is  necessary  for  the 
miners  to  live  in  the  immediate  vicinity  of  the  mines,  the  occupation 
may  be  said  to  have  as  close  a  relation  to  the  health  of  their  families 
as  to  their  own  health.  Insanitary,  frequently  filthy,  housing,  the 
almost  total  absence  of  pre-natal  or  maternity  care,  the  use  of 
untrained  midwives  in  confinement  cases,  the  inaccessibility  of  many 
mining  communities,  the  lack  of  facilities  for  public  health  education, 
have  combined  with  the  ignorance  of  the  miners  and  their  wives  to 
produce  a  state  of  affairs  that  is  often  shocking.  One  physician 
practising  in  the  bituminous  district  stated  that  tlie  infant  mortality 
among  miners'  children  was  fully  50  per  cent,  higher  than  in  the 
community  as  a  whole.  In  fact,  he  considered  it  a  question  of  the 
"survival  of  the  fittest,"  and  thought  that  the  deaths  of  the  weaker 
children  might  account  for  the  comparative  ruggedness  of  the  adults ! 


(1)  Report  of  Department  of  Mines,    1916. 


185 

Unfortunately  the  disregard  for  health  which  many  jnining  com- 
panies showed  when  they  built  for  their  employees  crowded  rows  of 
feur-room  houses,  fietpiently  full  in  the  smoke  and  gas  from  the  coke- 
ovens,  and  always  without  plumbing,  is  only  too  indicative  of  general 
housing  conditions  among  wage-earners  in  many  communities  where 
industry  is  directly  responsible  for  living  conditions,  and  yet, 
"standards  of  health  in  industry  cannot  be  effective  unless  decent 
living  quarters  are  provided.  Any  benefit  accruing  from  carefully 
equipped  shops  may,  be  entirely  dissipated  by  the  workers'  unwhole- 
some environment  in  leisure  hours — all  investigation  and  experience 
tend  to  show  a  constant  relationship  between  mortality,  morbidity, 
and  living  conditions.''^  The  extensive  experiments  made  in  indus- 
trial housing  on  a  large  scale  by  many  employers  during  the  war  is  a 
recognition  of  the  importance  of  the  problem  and  a  step  toward  its 
solution. 

Aside  from  the  prevalence  of  health  hazards  in  various  occupations, 
another  importa'nt  feature  in  the  relationship  between  work  and 
disease  is  the  problem  of  the  worker  himself.  Some  employees  are 
very  much  more  susceptible  to  certain  hazards  than  others,  so  much 
so  that  hygienic  as  some  industrial  processes  can  possibly  be  made, 
still  there  are  certain  classes  of  persons  who  should  not  engage  in 
them.  While  this  is  often  settled  by  natural  selection,  such  chance 
cannot  always  be  relied  upon,  especially  in  the  case  of  older  workers 
who  have  been  following  hazardous  occupations  for  years  and  who, 
although  weakened,  still  endeavor  to  continue.  An  increasing  num- 
ber of  employers  are  instituting  physical  examinations  for  applicants 
for  employment  as  a  means  of  meeting  this  difficulty.  Among  thirty- 
seven  industrial  plants  in  Pennsylvania  studied  by  the  United  States 
Public  Health  Service  in  April  and  May,  1918,  seventeen  required 
applicants  to  submit  to  physical  examination.  In  only  four  estab- 
lishments, however,  was  the  examination  used  as  a  basis  for  deter- 
mining the  exact  nature  of  work  to  which  the  applicant  should  be 
assigned.  In  most  cases,  the  examination  was  very  superficial,  com- 
municable diseases  and  obvious  defects  being  the  only  causes  for 
rejection. 

The  United  States  Bureau  of  Labor  Statistics  has  partially  com- 
pleted a  study  of  forty  years'  experience  of  the  "Workmen's  Sick  and 
Death  Benefit  Fund  of  America."  This  study  covers  approximately 
47,000  persons  of  all  ages  engaged  in  over  100  different  occupations. 
As  the  fund  has  no  waiting  period,  the  benefit  periods  are  an  accurate 
measure  of  sickness  among  the  members.  The  data  for  the  five  year 
period,  1912  to  1916,  has  been  compiled  and  made  available  for  the 
use  of  the  Commission,  by  Dr.  Royal  Meeker,  Chief  of  the  Bureau. 
As  shown  in  Table  I  the  occupations  have  been  classified  into  forty- 


(i)John  A.    Lapp,    Annals   of  the  American  Academy   of  Political   and    Social    Science,    January 
1919,  page  132. 


186 

two  groups,  within  which  the  proportion  of  members  ill  per  year 
ranged  from  12.2  per  cent,  for  professional  workers,  inchiding 
musicians,  draftsmen,  chemists,  opticians,  physicians,  dentists,  art- 
ists, writers,  reporters,  teachers,  lawyers  and  nurses,  to  31.40  per 
cent,  for  miners.  Ten  of  the  forty-two  occupational  groups,  miners, 
drivers,  liquor  manufacturing  employees,  "laborers,"  freight  handlers, 
molders,  tobacco  and  cigar  workers,  railway  employees,  tanners,  and 
blacksmiths,  had  over  25  per  cent,  of  their  members  ill  annually,  and 
in  only  nine  groups  was  the  percentage  less  than  20  per  cent. ;  in  54 
per  cent,  of  the  occupations  the  reports  showed  that  on  an  average 
from  20  per  cent,  to  25  per  cent,  of  the  members  were  ill  each  year. 

The  foregoing  facts  indicate  that,  aside  from  specific  occupational 
iliseases,  serious  health  hazards  exist  in  industry  today  and  make 
industry  in  large  measure  responsible  for  illness  among  employees 
and  their  families.  Great  improvement  could  be  made  by  the 
universal  institution  of  proper  methods  of  work  and  the  standardiza- 
tion of  working  conditions.  The  Industrial  Board  ^of  Pennsylvania 
nas  taken  a  step  in  this  direction  by  establishing  the  lighting  code  of 
U)l(>,  to  regulate  factory  illumination.  Following  a  two  years'  sur- 
v(^y  of  tlie  effect  of  industry  on  health,  the  Ohio  State  Board  of  Health 
declared  tliat  '^until  some  direct  incentive  to-  improve  factory  sani- 
tation is  offered,  little  real  progress  can  be  hoped  for."  Any  plan 
Tu  raise  health  standards  among  wage  earners  must  provide  this 
much  needed  stimulus. 

OCCUPATIONAL  DISEASES  IN  PENNSYLVANIA. 
By  Alice  Hamilton,    M.  D..    Bureau  of  Labor  Statistics,    Washington,    D.  C. 

Pennsylvania  is  probably  the  most  important  industrial  state  in 
the  Union.  Certainly  to  the  student  of  occupational  diseases,  it  is 
much  the  most  important.  No  state  has  so  wide  a  variety  of  those 
industrial  processes  which  carry  with  them  danger  to  the  workers 
either  because  of  poison  in  the  form  of  fumes,  liquids,  or  dusts,  or 
because  of  mechanically  irritating  dusts  which  injure  the  throat  and 
lungs. 

It  would  be  impossible  to  describe  in  detail  all  the  dangerous 
trades  of  Pennsylvania,  impossible  to  more  than  mention  those  that 
are  not  classed  as  dangerous  but  that  are  known  to  have  a  sickness 
rate  higher  than  tlie  average  for  industry.  Lead  poisoning  usually 
corner  first  in  order,  since  it  is  considered  by  far  the  most  important 
of  the  industrial  poisons. 

LEAD   POISONING. 

A  great  deal  of  lead  work  is  done  in  Pennsylvania.  In  the  Pitts- 
burgh region  much  molten  lead  is  used  in  making  machine  parts  and 
castings,  plumbers'  goods,  in  tempering  steel,  in  manufacturing  lead 
pipe,  sheet  lead  and  wire;  lead  compounds  are  used  in  enameling 
sanitary  ware,  and  in  grinding  paint;  white  lead  is  corroded  and 


■      187 

oxides  are  roasted.  The  Philadelphia  region  has  even  larger  white 
lead  works  and  oxide  roasters,  and  paint  factories.  Lead  oxides  are 
used  in  large  quantities  in  the  manufacture  of  storage  batteries  in 
Philadelphia,  and  the  shipyards  use  great  quantities  of  white  lead 
and  red  lead  paint.  In  several  parts  of  the  state,  tile  works  use  a 
lead  glaze,  and  there  are  many  brass  foundries  and  factories  in  which 
lead  poisoning  occurs  because  of  the  presence  of  lead  as  an  impurity 
in  the  brass.  There  are  also  factories  in  which  molten  lead  is  used, 
type  metal,  solder,  babbitt.  Rubber  works  use  lead  salts  in  com- 
pounding, small  refineries  work  up  lead  scrap,  dross,  and  lead  refuse 
of  all  kinds. 

No  figures  are  available  in  Pennsylvania,  or  for  that  matter  in 
any  state,  to  show  how  much  lead  poisoning  occurs  in  any  of  these 
industries.  Studies  made  for  the  Federal  Bureau  of  Labor  Statistics 
hayje  provided  us  with  information  concerning  the  chief  lead  indus- 
tries throughout  the  country  and  at  the  time  they  were  made  the 
I^ennsylvania  plants  did  not  differ  in  any  important  respect  from 
those  in  the  other  states  included  in  the  investigations,  nor  was  there 
any  reason  to  suppose  that  there  was  less  lead  poisoning  in  them  than 
in  those  of  other  states.  The  publications  of  the  Bureau  show  that 
in  1910-11  the  white  lead  industry  had  a  rate  of  about  18  per  cent, 
yearly  of  lead  poisoning.  In  enameling  sanitary  ware,  the  yearly 
rate  in  1011  was  21.4  per  cent.,  and  in  glazing  tiles  the  rate  during 
the  same  year  was  13.9  per  cent.  In  the  smelting  and  refining  of 
lead  tliere  was  a  little  over  22  per  cent,  of  lead  poisoning  in  1912. 
Making  storage  batteries  caused  lead  poisoning  in  almost  18  per  cent, 
of  all  those  employed  in  1913. 

Since  these  figures  were  compiled,  certain  of  the  lead  industries 
in  Pennsjdvania,  notably  the  making  of  white  lead  and  of  lead  oxides 
and  the  making  of  storage  batteries,  have  improved  very  greatly  and 
undoubtedly  have  a  much  lower  rate  of  poisoning  now.  Not  so  much 
improvement  has  taken  place  in  other  lead  trades,  indeed  it  is  doubt- 
ful whether  there  is  much  less  plumbism  in  the  smaller  refineries  and 
in  the  establishments  using  solder  and  casting  lead  than  there  was 
before  general  attention  was  called  to  this  kind  of  danger  to  work- 
men. The  notoriously  dangerous  lead  trades  have  been  made  much 
safer,  the  less  dangerous  ones  have  hardly  changed  at  all,  and  hospital 
records  that  used  to  carry  many  cases  from  white  lead  works  and 
storage  battery  works,  get  the  greater  number  of  their  cases  from 
among  solderers.  lead  burners,  type-founders  and  makers  of  tin  cans. 

Printers  and  painters  are  too  numerous  for  any  complete  investiga- 
tion concerning  their  rate  of  lead  poisoning.  Both  are  notoriously 
unhealthy  lead  trades,  the  latter  much  more  so  than  the  former.  The 
])rinting  trade  has  always  had  more  than  its  share  of  ill  health,  but 
it  is  impossible  to  be  sure  just  how  much  is  due  to  the  presence  of 


•    188 

lead  and  how  much  to  the  fact  that  it  is  an  indoor  trade  involving 
little  muscular  effort  and  much  nervous  strain.  In  the  course  of  an 
investigation  made  for  the  Bureau  of  Labor  Statistics,  it  was  found 
that  out  of  200  working  printers,  100  in  Chicago  and  100  in  Boston, 
18  or  19  per  cent,  had  lead  poisoning.  It  is  not  clearly  defined  lead 
poisoning,  however,  that  causes  most  of  the  ill  health  among  printers ; 
rather  the  lead  acts  in  lowering  the  resistance  to  tuberculosis  and  in 
encouraging  the  progress  of  the  so-called  "old  age"  or  degenerative 
diseases,  Bright's,  heart  disease,  general  arteriosclerosis.  Of  late 
years  the  printers  have  succeeded  in  lowering  their  tuberculosis  rate 
and  in  adding  to  the  average  duration  of  life,  but  an  increasingly 
large  number  are  now  suffering  from  old  age  diseases  during  the 
middle  years  of  life. 

The  most  severe  and  crippling  forms  of  lead  poisoning  are  found 
among  painters,  for  this  is  a  skilled  industry  and  men  do  not  drop  it 
easily  even  if  they  know  it  is  ruining  their  health.  The  examination 
of  a  hundred  painters  in  Chicago  in  1913  showed  that  no  less  than  59 
of  them  were  suffering  from  some  form  of  plumbism.  If  the  same 
proportion  holds  good  among  the  14000  journeyman  painters  in  the 
state  of  Pennsylvania,  there  must  be  some  8000  whose  health  is  some- 
what impaired  as  a  result  of  their  work.  Lead  poisoned  painters 
often  have  very  serious  forms  of  plumbism.  Among  100  lead  poisoned 
painters  in  Chicago,  there  were  42  cases  of  palsy,  9  cases  of  brain  dis- 
ease, 11  cases  of  impaired  sight  and  11  of  general  hardening  of  the 
arteries.  Painters  are  exposed  to  other  injurious  substances  besides 
lead,  to  the  benzine  or  naptha  in  quick-drying  paints,  to  benzol  in 
coal  tar  paints,  to  turpentine,  wood  alcohol,  carbon  tetrachloride  and 
to  carbon  monoxide  gas  which  rises  from  the  charcoal  stoves  placed 
in  new  buildings  to  dry  out  the  walls. 

Painting  in  factories  is  either  much  less  dangerous  than  house  and 
ship  painting  or  rather  more  so.  Instances  of  the  safe  branches  are 
the  painting  of  machinery  and  vehicles  with  leadless  paints  by 
dipping  them  in  vats  of  paint.  Instances  of  the  dangerous  forms  are 
the  painting  and  sandpapering  of  wheels  and  bodies  of  automobiles 
and  carriages  where  a  paint  rich  in  lead  is  used.  The  most  danger- 
ous work  for  the  journeyman  painters  is  interior  decorating  of 
houses,  requiring  manj^  coats  of  white  lead  paint  which  must  be 
sanded  down,  and  ship  painting  where  great  quantities  of  white  and 
red  lead  paints  are  used.  Ship  painting  employs  a  large  number  of 
painters  in  Pennsylvania. 

From  records  of  hospitals  in  Philadelphia  and  Pittsburgh  the  fol- 
lowing industries  were  shown  to  have  caused  lead  poisoning  severe 
enough  to  require  hospital  treatment.  The  well  known  lead  indus- 
tries are  not  included  here : 


189 

Grinding  lead  enamel  for  sanitary  ware. 

Sanitary  ware  enamelling. 

Lead  tempering. 

Lead  casting. 

Sweeping  up  scrap  and  dross  from  lead  casting. 

Unloading  lead  bullion  from  cars. 

Plumbing  trade. 

Making  lead  stoppers  and  perforated  filters  for  wa'shstands. 

Pouring  brass. 

Polishing  brass. 

Making  tin  ware. 

Soldering  tin  cans. 

Chipping  off  old  red  lead  paint. 

CARBON  MONOXIDE. 

This  is  probably  the  closest  rival  of  lead  as  an  occupational  poison. 
Carbon  monoxide  poisoning  is  yearly  on  the  increase  as  the  use  of 
producer  gas  for  heat  and  power  increases  and  as  the  automobile 
industry  increases.  All  incomplete  combustion  of  gas  is  accompanied 
by  the  production  of  carbon  monoxide,  but  the  gas  is  found  more 
especially  in  the  steel  foundries,  in  smelters,  brick  kilns,  enamelling 
furnaces,  bakeries,  laundries,  and  in  coke  by-products  works.  In 
testing  automobiles  many  cases  of  carbon  monoxide  poisoning  have 
occurred  through  the  escape  of  exhaust  gases  which  are  composed 
largely  of  this  compound.  Acute  carbon  monoxide  poisoning  is  far 
from  rare  in  the  great  steel  mills  of  the  Pittsburgh  region.  It  causes 
symptoms  of  dizziness,  weakness,  confusion  or  rapid  loss  of  con- 
sciousness which  may  end  in  death  in  a  very  short  time.  If  the  man 
recovers  from  this  attack  there  may  be  a  more  or  less  permanent  loss 
of  memory  and  mental  powers,  or  pneumonia  may  develop,  very  likely 
to  be  fatal.  Chronic  carbon  monoxide  poisoning  is  found  in  steel 
workers  and  also  in  pressers  in  tailor  shops  and  tailors  who  work  in 
the  same  room  with  them,  in  printers  working  in  shops  where  gas  is 
used  to  keep  lead  melted  and  there  are  no  pipes  to  carry  off  the 
fumes,  in  bakers  Avho  are  exposed  to  gas  fumes  and  in  solderers  of 
cans  who  use  the  heat  of  naked  gas  jets.  This  chronic  poisoning 
causes  an  increasing  anaemia  with  all  its  consequences,  loss  of  nutri- 
tion, loss  of  strength,  nervousness,  indigestion,  and  a  tendency  to 
infectious  disease,  especially  tuberculosis. 

BRASS. 
The  metallic  poisons  which  are  used  in  Pennsylvania  industries 
are  brass — an  alloy  of  copper  and  zinc — mercury,  arsenic  and  anti- 
mony. Brass  poisoning  as  often  described  is  really  lead  poisoning, 
for  brass  polishers  and  buffers  do  not  become  poisoned  by  the  solid 
brass,  if  they  are  poisoned  it  is  from  the  lead  so  often  present  in  the 
alloy.  Real  brass  poisoning  is  met  with  in  brass  founding  or  pour- 
ing, when  the  thick  white  fumes  given  off  are  allowed  to  escape  and 
contaminate  the  air  of  the  room.     The  sublimed  zinc  oxide  is  the 


190 

element  in  these  fnines  that  gives  trouble,  not  any  form  of  copper, 
and  zinc  smelters  suffer  from  the  same  kind  of  symptoms  as  do  zinc 
welders.  Brass  founders'  ague,  as  it  is  called  is  not  considered  a 
serious  affection  by  either  physicians  or  the  workmen  themselves.  It 
resembles  a  short  attack  of  chills  and  fever,  but  clears  up  rapidly. 
Nevertheless,  brass  workers  do  not  have  as  good  health  as  the  average 
of  men  employed  in  manual  work.  Probably  this  is  the  result  of 
exposure  not  only  to  brass,  but  to  lead  and  sometimes  arsenic,  to 
heat  and  abrupt  changes  of  temperature  and  heavy  work,  and  to  car- 
boli  monoxide  from  the  furnaces. 

MERCURY. 
Mercury  is  used  chiefly  in  the  making  of  felt  hats,  a  fairly  large 
industry  in  this  state.  The  rabbit  fur  used  for  felting  is  treated  with 
nitrate  of  mercury  and  all  who  handle  it  after  this  preliminary  "car- 
rotting"  are  liable  to  mercurial  poisoning.  This  is  a  notoriously 
nnhealthful  industry  all  over  the  civilized  w^orld.  In  addition  to  the 
presence  of  so  powerful  a  poison  as  mercury  there  is  the  irritating 
effect  on  the  lungs  of  the  particules  of  fur  in  the  air,  the  atmosphere 
of  steam  in  certain  departments,  and  the  wood  alcohol  used  in  shel- 
lacking the  felt.  The  felt  hat  industry  has  had  more  cases  of  indus- 
trial wood  alcohol  poisoning  than  has  any  other  trade. 

ARSENIC. 
Arsenic  s  present  as  an  impurity  in  much  iron  zinc  and  lead  ore 
and  also  in  much  of  the  mui^iatic  acid  and  sulphuric  acid  used  in 
industry.  When  such  an  acid  is  brought  in  contact  with  such  a 
metal,  arsenic  in  the  form  of  arseniurretted  hydrogen  is  given  off  and 
poisons  the  workman.  Lead  burners  get  it  from  the  hydrogen  which 
they  use  for  their  oxy-hydrogen  flame  and  wliicli  they  make  from 
muriatic  acid  and  zinc ;  makers  of  toy  balloons  get  it  frQm  the  hydro- 
gen used  to  fill  the  balloons.  Such  cases  are  seldom  rightly 
diagnosed,  for  there  is  nothing  in  the  industry^  to  suggest  arsenic  to 
the  physician.  The  making  of  arsenical  insecticides  is  not  carried  on 
in  Pennsylvania. 

VARIOUS  INDUSTRIAL  GASES. 

Gaseous  poisons  less  important  than  carbon  monoxide  are  sulphur 
dioxide,  nitrogen  oxides,  chlorine,  ammonia,  ether.  Sulphur  dioxide 
is  believed  by  many  practical  men  to  be  devoid  of  real  danger,  yet  it 
was  one  of  the  poisons  that  Germans  selected  for  experiment  when 
they  inaugurated  gas  warfare.  It  is  given  off  chiefly  in  the  making 
of  sulphuric  acid  and  in  tlie  making  of  carbolic  acid,  both  of  them 
carried  on  in  this  state.  Chlorine  is  given  off  during  the  early  stages 
of  nitric  acid  nmnufacture.  It  is  the  gas  that  was  used  almost 
exclusively  during  the  first  year  of  gas  warfare.  Ammonia  gas  may 
cause  m  mucli  irritation  of  the  respiratoi-y  tract  as  to  set  up  a  fatal 


191 

pneumonia.  It  is  used  in  refrigerating  plants  and  in  the  making  of 
artificial  ice,  and  to  a  less  extent  in  making  ammonium  nitrate  for 
the  explosive  industry. 

Nitrogen  oxides  are  a  danger  wherever  nitric  acid  is  made  or  use<l. 
The  manufacture  of  nitric  acid  has  increased  enormously  since  the 
war  and  so  has  its  use  in  the  making  of  exjylosives  all  of  which  are 
nitrated  products.  There  is  nothing  in  the  making  or  use  of  nitric 
acid  tliat  requires  the  escape  of  nitrous  fumes,  on  the  contrary,  every 
etfort  should  be  made  to  prevent  their  escape  in  the  interests  of 
economy  as  well  as  to  protect  the  workmen.  Of  recent  years  the 
handling  of  this  dangerous  acid  has  greatly  improved  and  there  is 
much  less  "fume  poisoning"  in  nitric  acid  works  and  in  the 
making  of  picric  acid,  nitro-cotton,  trinitrotoluol,  and  celluloid 
than  there  was  three  years  age.  Nevertheless  it  is  impossible 
to  altogether  prevent  the  leaking  of  pipes  or  vats,  for  strong 
nitric  acid  is  very  corrosive,  and  there  is  still  some  poison- 
ing from  this  gas  among  workers  in  Pennsylvania  acid  plants 
and  in  explosive  manufacture. 

COAL  TAR  PRODUCTS. 

Since  the  beginning  of  the  war,  when  supplies  from  Germany  were 
shut  off,  there  has  been  a  great  increase  in  Pennsylvania  of  industries 
involving  .exposure  to  coal  tar  products.  Formerly  a  certain  amount 
of  benzol  was  imported  from  Germany  but  it  was  costly  and  did  not 
find  extensive  use.  The  petroleum  derivatives,  naphtha  and  benzine, 
were  cheaper  and  more  abundant  and  they  were  used  largely  in  rub- 
ber manufacture,  making  quick-drying  paints,  paint  removers, 
varnishes,  shellacs  and  so  on,  to  be  a  better  solvent  than  naptha,  but 
it  was  too  expensive.  Since  the  war  benzol  has  been  manufactured 
on  a  large  scale  in  this  country  and  some  of  the  largest  plants  are  in 
Pennsylvania.  This  benzol  is  used  not  only  for  its  solvent  properties 
but  as  a  starting  point  for  the  manufacture  of  anilin.  The  latter  is 
then  used  to  make  anilin  dyes  and  also  in  compounding  rubber,  mak- 
ing type  roller  cleaners,  shoe  polishes,  and  one  of  the  high  explosives, 
tetryl. 

Closely  related  to  benzol  is  toluol,  extracted  from  illuminating  gas 
and  latterly  used  in  large  quantities  to  make  the  charge  for  high 
explosive  shell,  trinitrotoluol,  commonly  called  TNT.  Pennsylvania 
has  not  only  important  plants  for  the  nitration  of  toluol  and  the 
purification  of  crude  TNT,  but  also  at  least  one  large  shell  loading 
plant,  where  the  TNT  is  made  into  charges  and  loaded  into  shells,  and 
also  one  in  which  detonators  are  made  from  TNT  and  tetryl.  Benzol 
and  toluol  and  their  derivitives  are  all  poisons  to  the  blood  and  to  the 
nervous  system,  being  absorbed  largely  through  the  skin.  Benzol  is 
the  one  most  rapidly  poisonous,  a  short  exposure  to  heavy  fumes 
being  frequently  fatal.  Anilin  is  volatile  and  has  a  rapid  effect  but 
13  ' 


192 

is  not  so  serious  a  poison  as  TNT  which  is  more  slowly  absorbed  but 
for  that  very  reason  has  a  more  profound  effect  because  it  does  not 
give  prompt  warning  of  danger  as  does  anilin.  Tetryl  is,  so  far  as  is 
known,  only  slightly  poisonous,  producing  an  eruption  on  the  skin 
which  is  distressing  but  not  dangerous.  Toluol  is  like  benzol  in  its 
effects.  The  extraction  of  benzol  from  coal  tar  in  Pennsylvania  has 
•  been  followed  by  several  fatal  cases  of  benzol  poisoning. 

The  substitution  of  benzol  for  naphtha  and  benzine  means  that 
work  in  rubber  manufacture,  in  making  and  using  shellacs  and 
varnishes,  using  varnish  removers  and  paint  removers,  using  rubber 
cement  for  sealing  cans  and  dry  cleaning  and  dyeing,  are  probably 
more  dangerous  occupations  now  than  they  used  to  be.  Benzol  is 
also  used  in  another  new  industry,  the  manufacture  of  carbolic  acid. 
Chronic  benzol  poisoning  is  not  as  yet  very  easy  to  recognize,  but 
investigations  now  being  made  on  the  blood  of  benzol  workers  will 
probably  make  it  easier  to  discover  whether  the  ill  health,  the 
anaemia,  loss  of  strength,  nervous  symptoms,  and  sometimes  gastric 
symptoms,  found  among  those  who  work  with  benzol  are  caused  by 
the  benzol  or  by  other  factors. 

DISEASE  CAUSED  BY  PHYSICAL  AGENTS. 
This  is  a  fairly  full  list  of  occupational  poisons  used  in  Pennsyl- 
vania, but  though  they  cause  a  good  deal  of  industrial  sickness,  they 
are  not  by  any  means  as  important  as  are  certain  other  disease  pro- 
ducing factors  in  the  industry  in  this  state.  One  of  the  most  import- 
ant, if  not  the  most  important  industry  in  Pennsylvania,  is  the  manu- 
facture of  steel.  No  thorough  study  has  ever  been  made  of  the 
occupational  diseases  of  Pennsylvania  steel  workers,  but  we  know 
that  there  are  many  things  about  the  making  of  steel  which  are 
harmful  to  health.  Steel  workers  are  exposed  to  poisoning  not  only 
by  carbon  monoxide  but  sometimes  also  by  lead,  arsenic,  sulphuretted 
hydrogen  and  the  cyanides.  They  must  use  great  physical  strength, 
and  if  the  strain  is  too  great  for  the  heart,  there  may  be  an  acute 
dilatation  which  may  be  slow  in  recovery  or  may  be  permanent. 
Steel  workers  are  also  exposed  to  metallic  dust  and  to  sand,  to  great 
heat,  to  sudden  changes  of  temperature,  resulting  in  rheumatism, 
lumbago,  bronchitis,  and  to  light  of  such  character  and  intensity 
as  to  injure  the  eyes  if  they  are  not  protected.  To  all  these  injurious 
features  must  be  added  the  fatigue  of  the  long  work-day  and  the 
seven  daj^  week. 

TEXTILE  INDUSTRY. 
Another  very  important  industry  in  Pennsylvania  is  the  textile, 
which  is  regarded  as  unhealthful  in  all  civilized  countries.  The  bad 
features  in  the  textile  trades  are  first  the  light  fluffy  dust  of  cotton, 
or  wool,  more  rarely  flax;  the  fatigue  caused  by  noise,  jarring,  and 
monotonous  work  which  yet  demands  constant  attention;  the  heat 


193 

and  humidity.  These,  together  with  a  rather  low  wage  scale,  are 
all  factors  that  go  to  bring  about  an  abnormally  high  rate  of  tuber- 
culosis, in  the  textile  trades.  The  more  immature  the  workers,  the 
more  tuberculosis,  and  the  more  fatiguing  the  work,  the  more  tuber- 
culosis. Many  girls  between  the  ages  of  sixteen  and  twenty-four 
are  employed  in  the  mills  in  and  around  Philadelpliia  and  it  is 
just  in  this  age  group  that  the  incidence  of  industrial  tuberculosis 
is  heaviest. 

COAL  MINING. 

Another  important  industry  in  Pennsylvania  is  coal  mining. 
Coal  miners  have  a  high  accident  rate  and  that  fact  affects  their 
sickness  rate.  Accidents  usually  kill  off  or  incapacitate  men  in  the 
earlier  age  groups,  the  very  groups  in  which  tuberculosis  is  usually 
most  prevalent.  It  is  well  known  that  coal  miners  do  not  have  as 
much  pulmonary  tuberculosis  as  does  the  population  at  large  and 
because  of  this  fact  there  is  a  general  impression  that  the  coal  min- 
ing industry  is  unusually  healthful.  Coal  miners  more  than  make 
up  for  their  low  tuberculosis  rate  by  their  high  rate  of  deaths  from 
other  respiratory  diseases.  This  is  shown  by  a  recent  analysis  made 
of  the  mortality  of  the  two  coal  mining  cities  of  Scran  ton  and 
Wilkes-Barre  compared  with  the  mortality  for  the  whole  state  of 
Pennsylvania.  The  reason  for  the  excessive  high  death  rate  from 
non-tuberculous  diseases  of  the  lungs  is  usually  given  as  follows — 
Coal  dust  is  not  very  irritating  and  does  not  cause  the  sort  of  injury 
to  the  lung  tissue  which  is  caused  by  steel  or  stone  dust  and  w^hich 
prepares  the  way  for  a  tuberculous  inflammation.  The  effect  of 
coal  dust  is  to  cause  a  very  slow  hardening  of  the  lung  which  may 
produce  no  symptoms  or  may  cause  asthma.  If,  however,  the  miner 
contracts  pneumonia,  the  hardened  state  of  his  lungs  diminishes 
very  much  his  chance  of  recover}^ 

COMPARATIVE  MORTALITY  OF  PENNSYLVANIA,   1911  TO  1915. 
(Rate  per  100,0000  population). 


Cause  of  Death. 


Scran  ton. 

Wilkes- 
Barre. 

79.9 
16.6 
261.2 
153.5 

74.9 

19.4 

212.5 

179.7 

Remainder 
of  State. 


Pulmonary  tuberculosis, 

Other  tuberculosis,   

Respiratory  diseases,   _. 
Violence,  _ 


110.5 
16.4 

184.2 
98.9 


ANTHRAX. 
Pennsylvania  being  a  seaboard  state  with  an  important  port  at 
Philadelphia,  has  had  a  comparatively  large  number  of  cases  of  that 
rather  unusual  industrial  disease,  anthrax  or  malignant  pustule. 
Anthrax  is  caused  by  a  very  resistant  bacillus  which  sets  up  a  fatal 
disease  in  cattle.     It  is  especially  in  hides  that  are  shipped  to  this 


194 

country  from  abroad  that  this  infection  is  found.  Even  careful 
disinfection  before  shipping  is  not  always  enough  to  kill  the  germ 
of  anthrax  which  may  retain  its  vitality  and  weeks  later  infect  the 
man  who  unloads  the  hides  or  sorts  them  or  carries  them  through 
the  processes  of  washing  and  tanning. 

Between  January  1st,  1913  and  January  1st,  191G,  there  were  19 
cases  of  anthrax  in  Pennsylvania,  eight  of  them  women.  Seven  of 
the  27  cases  reported  during  the  first  half  of  this  period  are  known 
to  have  been  fatal,  and  out  of  132  deaths  from  anthrax  reporte  1 
throughout  the  registration  area  of  the  United  States  in  a  period  of 
five  years,  1910-1915,  13  occurred  in  Pennsylvania. 

The  women  who  contracted  anthrax  were  sorting  hair  and  twist- 
ing hair  or  were  working  in  tanneries;  the  men  had  occupations 
of  great  variety.  They  were  hide  and  skin  workers,  wool  and  hair 
workers,  longshoremen  unloading  hides,  laborers  in  tanneries,  and 
there  was  one  representative  of  each  of  the  following  occupations, 
inspecting  raw  stock,  sorting  raw  hides,  fixing  a  haircloth  loom, 
handling  dirty  rags  for  shoddy,  handling  hoofs  in  a  glue  factory, 
examining  haircloth,  making  brushes,  working  in  a  livery  stable. 
In  addition  there  were  two  babies,  one  the  child  of  a  tanner,  the 
other  the  child  of  a  coal  miner,  apparently  infected  from  some 
unknown  soource. 

There  is  no  compensation  for  occupational  disease  in  Pennsylvania. 
In  this  respect  some  states  are  more  fortunate  but  it  would  be  a 
great  mistake  to  think  that  the  passage  of  a  law  providing  coni- 
I)ensation  for  occupational  diseases  would  do  away  with  the  poverty 
that  is  really  attributable  to  sickness  set  up  by  or  increased  by  the 
workers'  occupation.  It  is  true  that  we  are  learning  each  year 
more  about  the  action  of  various  poisons  on  the  human  body  and 
also  about  such  indirect  factors  in  the  production  of  disease  as 
fatigue,  heat,  and  humidity.  Nevertheless  we  can  connect  occupa- 
tional disease  only  in  a  small  number  of  cases  with  that  degree  of 
positiveness  that  would  be  required  under  the  law.  It  is  only  when 
the  disease  is  caused  by  a  poison  whose  symptoms  are  unmistake- 
a'ble  or  by  acute  infection  with  a  germ  that  can  be  identified,  or 
when  it  is  caused  by  some  physical  agent  such  as  excessive  heat  or 
the  pressure  of  air  in  a  caisson  that  we  can  actually  prove  the  occu- 
pation to  be  responsible. 

Nobody  has  any  difficulty  in  deciding  that  lead  colic  or  lead  con- 
vulsion in  a  white  lead  worker  should  be  charged  up  to  his  occu- 
pation, but  it  is  a  very  different  thing  to  prove  that  a  general  hard- 
ening of  the  arteries,  with  Bright's  disease  and  perhaps  softening 
of  the  brain  in  a  lead  caster  who  has  never  had  lead  colic,  is  caused 
by  his  occupation.  Always  there  is  far  more  doubt  about  the  occu- 
pational factor  when  the  poisoning  is  chronic  than  when  it  is  acute, 


195 

and  yet  industrial  poisoning  is  typically  chronic,  exceptionally  acute.^ 
There  have  been  some  very  startling  cases  of  acute  benzol  poisoning 
in  Pennsylvania  that  attracted  attention,  were  investigated  by  the 
state  authorities,  and  were  made  the  ground  for  orders  tending  to 
prevent  such  accidents  in  the  future.  But  for  every  case  of  that 
kind  there  are  probably  twenty  or  more  of  slow,  chronic  poisoning 
with  benzol  in  rubber  works,  in  canneries,  in  straw  hat  manufac- 
ture, wjien  rosin  is  used  for  sealing  cans  and  in  cleaning  and  dyeing. 
In  the  great  rolling  mills  around  Pittsburgh,  eveiy  now  and  then 
a  foundryman  is  overcome  with  the  fumes  of  carbon  monoxide,  ren- 
dered unconscious  perhaps,  and  when  he  recovers  his  senses,  he  is 
confused  and  mentally  unsound  for  some  time,  or  contracts  pneu- 
monia within  a  short  time.  Such  a  case  is  undoubtedly  occupational, 
and  nobody  thinks  of  questioning  it.  But  for  every  case  of  so-called 
"gassing"  in  the  mills,  there  are  probably  a  hundred  cases  of 
anaemia  and  malnutrition  and  neurasthenic  troubles  among  pressers 
in  tailor  shops,  bakers,  metal  casters,  linotypists  and  electrotypers, 
all  of  whom  work  day  after  day  in  air  slightly  contaminated  by  tlie 
fumes  of  carbon  monoxide  from  naked  gas  burners.  So  also  a  case 
of  anthrax  in  a  tannery  worker,  which  develops  into  fatal  blood 
poisoning  is  recognized  as  occupational,  but  tuberculosis  developing 
slowly  ill  a  sandblaster  of  sanitary  ware  is  not  so  recognized. 

Many  other  instances  could  be  cited  to  show  that  while  acute 
industrial  poisoning  can  be  readily  recognized,  chronic  poisoning  con- 
stitutes a  much  harder  problem,  but  even  more  difficult  is  the  prob- 
lem when  we  try  to  trace  the  connection  between  occupation  and 
disease  in  those  trades  where  dust  is  the  danger,  dust  that  is  not 
poisonous  or  perhaps  only  slightly  so.  Felt  hat  makers  have  a  high 
tuberculosis  rate  and  the  injurious  effect  of  the  fine  particles  of  fur 
in  the  air  they  breathe  is  doubtless  increased  by  the  presence  of  the 
mercurial  salt  with  which  the  fur  has  been  treated,  but  if  a  hat 
maker  shows  no  symptom  of  mercurial  poisoning,  only  of  consump- 
tion, it  is  not  easy  to  prove  that  he  contracted  the  disease  in  the 
course  of  his  work.  The  samfe  difficulty  is  seen  in  occupations  where 
metallic  lead  dust  is  present.  We  know  that  lead  poisoning  and 
tuberculosis  go  hand  in  hand  and  that  a  lead  trade  in  which  men 
remain  for  many  years  always  has  a  high  tuberculosis  rate,  but  if 
a  consumptive  printer  does  not  give  a  history  of  lead  colic,  how  are 
we  to  prove  that  his  occupation  has  brought  on  his  disease. 

The  dusty  trades,  undoubtedly  responsible'^for  more  disease  than 
any  other  class  of  occupations,  because  they  employ  so  many  more 
people  than  do  the  notoriously  dangerous  trades,  are  not  adequately 
covered  in  any  state  by  the  laws  designed  to  prevent  disease  or  to 
compensate  workmen  suffering  from  such  disease,  for  this  very  rea- 
son, the  difficulty  of  proving  the  responsibility  of  the  occupation. 
The  dust  that  causes  the  harm  is  not  the  coarse,  heavy  dust  that 


196 


\ 


is  easily  seen  and  that  the  factory  inspector  can  insist  on  having 
done  away  with.  Such  dust  cannot  reach  the  lungs  and  injure  them. 
It  is  the  fine,  almost  invisible  particles  that  do  the  real  harm, 
because  they  can  pass  in  with  the  breath  and  be  carried  down  to 
the  lungs.  The  commonest  form  of  injury  by  dust  is  a  slowly  devel- 
oping fibrous  change  in  the  lungs  which  may  become  the  seat  of 
a  tuberculosis  if  anything  happens  to  lower  the  worker's  vitality,  or 
which  may  prevent  his  recovery  if  he  contracts  pneumonia.-  Obvi- 
ously, no  matter  how  positive  we  may  feel  that  such  results  can 
follow  long  exposure  to  fine  atmospheric  dust,  we  shall  always  find 
it  difficult  to  prove  that  any  individual  case  of  consumption  or  of 
death  from  pneumonia  was  caused  by  a  dusty  occupation.  This 
means  that  no  law,  no  matter  how  wide  its  application,  will  ever 
cover  all  cases  of  occupational  disease. 

Part  II.— Section  IV.— Table  I. 
WORKMEN'S   SICK  AND  DEATH  BENEFIT  FUND  OF  AMERICA, 

1912-16.(1) 


Occupation. 


Barbers, 

Bartenders,  

Bricklayers,    

Carpenters,    

Paintersj    

Plasterers,  

Plumbers,    

Sheet  metal  workers,  

other  building  construction,  

Oooks  and  waiters,  

Engineers  and  firemen,  stationary  or  power  house,  - 

Farmers,  gardeners,  florists, 

Freight  handlers,  

Laborers,  not  specified,  __ 

Auto,  carriage  and  wagon  manufacturing  employes 

Clay  products  manufacturing  employes,  

Clothing  manufacturing  employes,  

Dyers,    

Electrical  workers,    

Food— other  than  slaughtering  and  meat  packing,  _ 

Slaughtering  and  meat  packing,  

Glassworkers,    ,- 

Jewelers,    

Tanners,    

Leather  workers,   

Liquor  manufacturing  employes,  

Blacksmiths,    

Machinists,    

Holders,  

other  metal  workers,   

Printers,    

Stone  and  granite  workers, 

Textile  manufacturing  employes,  

Tobacco  and  cigars,  — 

Other  manufacturing  employes,  

Miners,    

Professional,  — 

Trade  and  clerical, 

Drivers,    

Railway  employes,  — 

Woodworkers,    

All  other  occupations,  


Number 

Number 

Per  Cent. 

of 

Receiving 

of 

Members. 

Benefits. 

Membership, 

1,242 

228 

18.3 

2,290 

404 

17.6 

2,241 

539 

24.05 

11,690 

2,820 

24.1 

4.389 

926 

21.09 

558 

109 

19.5 

1,448 

326 

22.5 

2,343 

514 

21.9 

588 

122 

20.7 

2,339 

484 

20.6 

3,378 

766 

22.6 

1,203 

243 

20.1 

724 

199 

27.4 

17,700 

4,886 

27.4 

735 

180 

24.4 

652 

144 

22.08 

4,847 

883 

18.2 

748 

164 

21.9 

988 

215 

21.7 

7,507 

1,540 

20.6 

5,724 

1,351 

23.6 

965 

222 

23.2 

1,169 

166 

14.2 

1,466 

370 

25,2 

4,316 

941 

21.8 

14,324 

4,038 

28.1 

2,053 

518 

25.1 

16,026 

3,567 

22.2 

2,838 

737 

25.9 

6,907 

1,606 

23.2 

3,401 

591 

17.3 

1,172 

273 

23.2 

7,287 

1,343 

18.4 

8,897 

2,301 

25.8 

4,164 

876 

21.03 

7,068 

2,220 

31.4 

1,192 

146 

12.2 

5,591 

956 

17.09 

6,890 

1,977 

28.6 

699 

177 

25.3 

6,093 

1,336 

21.9 

9,258 

2,109 

22.7 

(1)  A  compilation  was  made  of  the  data  for  each  year,  and  this  was  combined  for  the  five 
year  period.  The  combined  figures  for  the  five  years  represent  the  individual  member  one  to 
five  times  according  to  his  period  of  membership. 


PART  II. 

SECTION  V. 

Sickness  Prevention. 


(197) 


m 


(198) 


'     199 

SICKNESS  PREVENTION. 

It  would  be  hard  to  over-estimate  the  importance  of  sickness  pre- 
vention, the  fifth  subject  assigned  to  the  Commission  for  investiga- 
tion. The  Committee  of  One  Hundred  on  National  Health,  in  its 
"Report  on  National  Vitality,"  stated  that  ^'at  least  fourteen  years 
could  be  added  to  human  life  by  the  partial  elimination  of  prevent- 
able diseases  *  ♦  ♦  The  actual  economic  saving  annually 
possible  in  this  country  by  preventing  needless  deaths,  needless  ill- 
ness (serious  and  minor),  and  needless  fatigue,  is  certainly  far 
greater  than  one  and  a  half  billions  and  may  be  three  or  more  times 
as  great. "^ 

^'Prevention"  has  come  to  be  the  key  note  of  health  policies.  It 
is  beirrg^^pfovedr  that  science  and  care  can  produce  a  stronger  race, 
and  that  a  policy  which  not  only  cares  for  ills  when  they  arrive, 
but  uses  every  effort  to  prevent  them,  is  a  policy  of  real  economy 
and  efficiency. 

Ideas  of  public  health  work  have  materially  changed  within  the 
last  few  years.  In  its  essence  the  change  has  been  to  place  the 
emphasis  on  "people"  as  well  as  on  "things."  The  old  method  of 
concentrating  entirely  on  swamps,  damp  cellars,  garbage-collection 
and  the  disposal  of  sewage,  was  not  effective  in  the  largest  sense, 
for  disease  continued  to  exist  where  things  were  all  light,  among^ 
the  rich  and  the  poor,  in  good  houses  and  in  bad. 

In  preventive  work  among  people  two  methods  have  been  used. 
Impersonal  education,  in  the  way  of  literature,  meetings,  exhibits, 
andTIie"like;  and  personal  education,  carried  to  the  individual  largely 
through  the  public  health  nurse.  "By  public  health  nurse  is  meant 
not  only  a  nurse  employed  by  municipalities  or  public  officials,  such 
as  schools,  health  departments,  etc.,  but  any  graduate  nurse  who 
is  doing  some  form  of  social  work  in  wliich  her  training  as  a  nurse 
comes  into  play  and  is  recognized  as  a  valuable  part  of  her  equip- 
met.  Her  scope  is  not  necessarily  confined  to  districts,  nor  is  her 
work  limited  to  the  early  conception  of  the  nurse's  province — simply 
the  bed-side  care  of  the  sick."  This  nurse  attempts  to  teach  the 
simple  laws  of  health  and  hygiene  in  relation  to  the  individual  and 
the  home ;  in  other  words,  she  tries  to  teach  people  how  to  get  well, 
how  to  keep  well,  and  how  to  keep  sickness  from  others.  Dr.  C.  E.  A. 
Winslow  of  Yale  Unversity,  one  of  the  leading  sanitarians  and  public 
health  authorities,  says,  "Among  modern  institutions  for  the  pro- 
tection of  public  health,  the  visiting  nurse  is  the  most  important 
figure." 

The  Metropolitan  Life  Insurance  Company  has  fully  realized  the 
value  of  the  principle  of  prevention  and  of  the  Visiting  Nurse.  In 
IDOO  this  Company  introduced  Visiting  Nurse  Service  for  its  indus- 

(1)  Pages  103  and  120. 


200 

trial  policy  holders  in  New  York  City  as  an  experimental  means 
of  diminishing  claim-rates  through  reducing  mortality  among  these 
policy-holders.  The  results  were  so  satisfactory  that  the  service 
was  rapidly  extended  to  other  cities,  and  by  1916  was  available  to 
90  per  cent,  of  the  holders  of  industrial  policies  in  over  2,000  cities 
in  the  United  States  and  Canada.  In  1916,  221,566  patients  received 
nursing  care,  at  a  cost  to  the  Company  of  over  |600,000.  However, 
the  constant  improvement  in  mortality  experience  of  the  Company, 
during  this  period,  has  amply  repaid  them  for  such  expenditures. 
From  1911-1915  the  decline  in  the  mortality  rate  among  industrial 
policy  holders  was  9.7  per  cent.,  while  for  the  entire  National  Regis- 
tration Area  it  was  but  4.9  per  cent.  The  following  table  shows  this 
decline  through  1916. 

RATES  PER  100,000  FOR  CERTAIN  CAUSES  OF  DEATH,  1916  AND  1911 

COMPARED. 

Metropolitan  Life  Insurance  Company    (Industrial  Department)    and  Registration 
Area  of  the  United  States.     (White  and  Colored  Lives  Combined). 


Metropolitan  Life  In- 
surance company  (In- 
dustrial Department).* 

Registration  Area 

in  United  States 

of  America. 

Causes  of  Death. 

Bates  per 

100,000. 

Per 

Cent. 
of  De- 
crease 
in  5 
Years. 

Rates  per  ' 

100,000. 

Per 
Cent, 
of  De- 
crease 

in  5 
Tears. 

1916. 

1911. 

1916.        1911. 

All  causes  of  death, _    _        _    _ 

1,168.1 

1,253.0 

6.8 

1,398.9 

1,415.9 

1.2 

Typhoid    fever, 

12.9 

40.4 
171.5 
17.4 

98.8 

22.8 

58.9 

203.0 
19.8 

97.9 

43.4 

31.5 
15.5 
12.1 

t.9 

13.3 

39.1 

123.8 

16.3 

105.1 

21.0 

49.0 

138.0 

16.0 

107.3 

36.7 

Acute  infectious  diseases  of  childhood  (measles, 

scarlet  fever,  whooping  cough,  diphtheria),  _. _ 
Tuberculosis   of   the  lungs,    

20.2 
10.3 
tl.9 

External  causes   (accidents,    suicides  and   homi- 
cides,                   —         -                             

2.1 

♦Metropolitan  exposure  and  deaths  contain  no  persons  under  one  year  of  age;  Registration 
Area  rates  are  on  basis  of  estimated  population  and  deaths  at  all  ages. 
tPer  cent,  increase  in  5  years. 

With  the  exception  of  "external  causes,"  the  rate  among  Industrial 
policy-holders  has  decreased  in  every  instance,  in  much  greater  pro- 
portion than  the  corresponding  rate  for  the  Registration  Area.  The 
greatest  reductions  in  every  instance  appear  in  those  diseases  to 
which  the  Company's  Nursing  Service  is  giving  particular  attention. 
The  maternity  service  comprises  one-fifth  of  the  entire  nursing  serv- 
ice among  industrial  policy  holders  of  the  Company;  the  decrease  in 
the  death  rate  from  diseases  relating  to  child  birth  has  been  over  12 
per  cent.,  while  the  population  at  large  has  suffered  an  increase  of 
nearly  two  per  cent.  From  11)11  to  1915,  the  death  rate  from  diseases 
of  the  puerperal  state  fell  from  72.9  per  100,000  to  05.3;  a  decline  of 
10.4  per  cent.  During  this  same  time  the  decline  in  the  Registration 
Area  was  but  4.5  per  cent. 


201 

In  explaining  the  remarkable  improvement  in  the  death  rate  of 
its  policy-holders,  the  Company  says,  "It  is  impossible  to  dis-associ- 
ate  the  effect  of  the  nursing  service  from  that  of  the  other  activities 
of  the  Company  and  from  the  results  of  the  public  health  work  of 
the  communities.  The  extensive  distribution  of  the  Company's  edu- 
cational literature,  the  cooperation  with  health  officers  and  the  very 
excellent  activities  of  so  many  of  the  local  and  state  departments 
of  health,  have  all  played  an  important  part  in  determining  the  favor- 
able returns.  But  the  country-wide  extension  of  the  nursing  service 
to  include  over  200,000  patients  annually,  the  intensive  work  done 
often  in  the  nature  of  emergent  relief,  the  education  in  personal 
hygiene  which  follows  the  more  than  a  million  visits  made  by  the 
nurses  to  industrial  homes,  together  must  be  credited  with  a  large 
share  in  the  mortality  reduction.  In  no  other  way  can  we  explain 
the  more  favorable  condition  which  prevails  among  the  insured  than 
among  the  general  population.''^ 

Another  evidence  of  what  can  be  done  by  intensive  preventive 
effort  through  personal  education  and  early  medical  treatment  in  a 
restricted  community  is  furnished  by  the  attempts  at  group  medicine 
now  being  made  in  the  clinic  systems  of  the  University  of  Wisconsin 
and  of  the  University  of  California.  In  Wisconsin  it  is  claimed  that 
the  work  of  the  Clinic  has  improved  in  a  marked  degree  the  health 
of  the  students  by  enabling  them  to  have  attention  as  soon  as  it  is 
needed,  and  thus  to  escape  long  illnesses  which  they  would  have 
suffered  had  they  not  had  early  care.  The  percentage  of  students 
seeking  medical  advice  has  increased  markedly  each  year  owing  to 
the  fact  that  they  have  learned  the  value  of  this  early  treatment, 
which  has,  in  turn,  brought  a  decrease  in  the  amount  of  serious 
illness.  In  1910-1911  at  no  time  more  than  20  per  cent,  of  the  stu- 
dents sought  medical  advice,  while  in  the  three  years  following  this 
proportion  increased  to  25,  29,  and  37  per  cent.,  respectively.  In 
the  last  year,  1913-14,  the  increase  was  uniformly  great  through- 
out the  months  of  the  college  year.  The  percentage  of  the  student 
body  seeking  medical  advice  on  February  1,  1914  was  almost  double 
the  percentage  at  the  corresponding  time  in  1911.  The  number 
reporting  on  October  1,  1913  was  six  times  the  corresponding  num- 
ber for  1910;  the  increase,  in  short,  was  felt  throughout  the  entire 
college  year,  because  of  the  educational  effort  to  secure  early  report- 
ing and  prevent  serious  illnesses. 

Owing  to  this  early  treatment  the  number  of  complications  in 
cases  of  grip,  for  instance,  has  fallen  steadily.  In  December  1910, 
one-fifth  of  the  student  body  reported  grip,  and  58  per  cent,  of  these 
"grip"  cases  developed  complications  such  as  inflammation  of  the 
ear,  eve,  etc.     In  December  1913,  when  almost  two-fifths  of  the  stu- 


(MLee  K.    Frankel   and  Louis  I.    Dublin,    "Visiting  Niirsing  and   Life  Insurance,"    June,    1918, 
page  55. 


202 

dent  body  reported  the  disease  but  four  per  cent,  developed  compli- 
cations; the  percentage  of  complications  developing  decreased  as 
the  percentage  of  students  seeking  medical  advice  increased. 

The  clinic  claims  that  likewise  the  average  time  lost  by  students 
because  of  illness  has  been  greatly  reduced,  from  eight  and  one-half 
days  in  1910-1911  to  two  and  one-half  days  in  1913-14.  Certainly 
nothing  could  speak  more  strongly  for  the  results  of  preventive  work 
and  early  treatment. 

The  statistics  of  the  University  of  California  compulsory  clinic 
plan  are  even  more  striking.  This  clinic  is  financed  by  a  compulsory 
fee  of  |3.00  a  semester,  which  each  student  pays.  As  the  student 
body  increases,  the  medical  staff  increases.  The  primary  purpose  of 
the  work  is,  according  to  Dr.  Legge,  to  establish  a  place  Avhere  ^'stu- 
dents can  be  scientifically  treated  before  a  serious  condition  devel- 
ops, and  through  educational  means  taught  how  to  live,  thereby  elim- 
inating disease  by  every  available  measure."^ 

To  accomplish  this  end  every  health  measure  deemed  necessary 
is  enforced  among  the  students.  Each  student  is  given  a  medical 
examination  on  entrance,  and  in  this  way  it  is  "possible  to  inform 
him  correctly  as  to  his  abilities  for  physical  exercises,  class-room 
work,  college  sports,  etc.  Numerous  defects,  local  infections,  and 
occasionally  graver  conditions  which  might  also  jeopardize  the  health 
of  others  and  be  a  menace  to  the  community,  are  detected  and 
treated.  Often  students  are  relieved  of  imaginary  diseases.  In  1915 
we  found  that  64  per  cent,  of  the  freshmen  had  errors  of  sight  refrac- 
tion, and  our  occulist  wrote  700  prescriptions  for  proper  glasses.  The 
dental  examination  revealed  that  only  82  men  and  56  women  out 
of  1.513  students  had  normal  teeth.  Numerous  other  illustrations 
could  be  cited,  such  as  postural  defects,  diseased  tonsils,  chest-dis- 
eases, etc."^ 

During  the  year  1915-16  the  average  number  of  daily  dispensary 
cases  was  126.3,  with  an  average  number  of  annual  treatments  per 
individual  patient  of  7.8.  Throughout  the  college  year,  4,516  stu- 
dents received  medical  treatment  or  advice.  This  was  71  per  cent, 
of  the  total  enrollment.  "To  the  uninformed,"  says  Dr.  Legge,  "it 
might  appear  that  this  large  percentage  of  cases  would  indicate 
unusual  morbidity,  but  as  a  matter  of  fact  the  purpose  is  to  encour- 
age early  advice  for  incipient  conditions,  thereby  avoiding  graver 
complications  and  development, — the  practical  application  of  the 
'stitch  in  time.'  "^ 

It  should  not  be  necessary  to  emphasize  the  necessity  of  a  further 
application  of  the  "stitch  in  time"  theory.  In  the  tabulated  causes 
of  rejection  in  the  report  of  the  Provost  Marshal  General  on  the 
operation  of  the  first  selective  draft,  fully  50  per  cent  of  the  rejections 


(1)  Robert  T.   Legge,   California  State  .Tournal  of  Medicine,   April,    1917. 


203 

were  shown  to  be  due  to  causes  which,  if  treated  in  time,  would  have 
been  preventable  or  correctable.  Twenty-two  per  cent,  were 
attributed  to  eye  conditions,  six  per  cent,  to  ear,  nine  per  cent,  to 
teeth,  and  four  per  cent,  to  physical  under-development. 

When  we  turn  to  the  actual  work  being  done  in  Pennsylvania  to 
reduce  sickness  and  promote  health,  we  find  that  it  is  carried  on 
principally  by  state  and  local  boards  of  health  and  by  various  private 
agencies. 

Especially  in  the  large  cities,  much  of  the  work  of  sickness  preven- 
tion is  carried  on  by  private  agencies.  In  Philadelphia  alone  approxi- 
mately 1200,000  was  spent  in  this  way  in  1917  by  fifty  or  more  organi- 
zations, including  hospital  social  service  departments,  child- welfare, 
housing  and  visiting  nurse  societies.  There  arerat  work  throughout 
the  state  some  630  public  health  nurses,  only  274  of  whom  are  paid 
from  public  funds.  By  spreading  a  knowledge  of  personal  hygiene 
and  child  welfare,  of  community  sanitation  and  of  methods  of  disease 
prevention,  these  public  health  nurses  are  doing  a  work  of  inestimable 
value,  and  through  their  contact  with  the  individuals  they  are  able  to 
interpret  their  health  message  in  the  language  of  that  individual's 
needs.  Approximately  a  third  of  all  these  nurses  are  in  Philadelphia, 
and  seventy-five  more  are  centered  in  Pittsburgh;  Wilkes-Barre, 
Scranton,  Erie,  Harrisburg,  York  and  Reading  have  from  ten  to 
fifteen  nurses  each,  and  the  remainder  are  scattered  through  the  state. 
Of  the  630,  approximately  260  are  doing  general  visiting  nursing ;  130 
are  tuberculosis  nurses,  100  are  child  welfare  nurses,  eighty  are  school 
nurses,  and  sixty  are  rendering  nursing  service  in  industrial 
plants.^ 

Much  educational  work  is  undertaken  by  the  private  organizations 
promoting  health  standards,  as  exampled  by  such  publicity  work  as 
that  done  by  Housing  Associations  and  by  the  Pennsylvania  Society 
for  the  Prevention  of  Tuberculosis.  Here  educational  health  work 
has  been  carried  into  the  schools,  the  moving  pictures  and  the  press, 
and  bulletins  are  regularly  issued  in  which  health  standards  are  set 
forth.  Much  preventive  work  is  carried  on  indirectly  by  different 
types  of  social  agencies  emphasizing  diet,  cleanliness,  and  carrying, 
as  does  the  public  health  nurse,  a  message  of  hygiene  to  the  individual 
fa^iily.  The  importance  of  work  of  this  sort  done  by  the  hospital 
dispensaries  and  the  hospital  social  service  workers  as  well  as  by 
private  physicians,  cannot  be  overestimated. 

Certain  progressive  employers  in  all  parts  of  the  state  have  insti- 
tuted measures  for  disease  prevention,  and  may  have  employed  fac- 
tory doctors  or  industrial  nurses,  or  both.  Such  work  is  of  great 
value,  but  is.  in  the  nature  of  things,  confined  to  the  larger,  more  pro- 
gressive companies,  where  disease-producing  conditions  are  likely  to 


(1)  Owing  to  war  conditions,   exact  figures  are  not  available. 


204 

be  reduced  to  the  minimum.  Like  any  voluntary  health  insurance,  it 
covers  least  those  who  need  it  most.  Far  too  often  it  is  limited  to 
industrial  accidents,  or  to  first  aid  measures  and  the  treatment  of 
obvious  disabilities,  in  a  dispensary.  The  work  is  therefore  super- 
ficial and  does  not  touch  either  the  larger  and  more  serious  group  of 
diseases  of  a  non-accidental  nature,  or  the  more  far-reaching  field  of 
prevention,  which  goes  back  to  the  causes  of  sickness  within  both  the 
factory  and  the  home. 

Besides  the  multitude  of  private  agencies,  the  state  has  recognized 
its  responsibility  for  the  preservation  of  health  by  the  establishment 
of  the  State  Department  of  Health,  all  the  work  of  which  is  in  reality 
largely  preventive.  In  addition  to  its  general  work,  the  State 
Department  of  Health  has  direct  control  of  all  public  health  work 
in  the  1,783  townships  having  a  population  of  less  than  250  to  the 
square  mile.  Altogether  these  rural  communities  contain  2,225,000 
persons,  or  about  one  quarter  of  the  population  of  the  state. 
Through  educational  publicity  work  of  all  sorts,  the  Department 
attempts  to  teach  people  how  to  keep  from  getting  sick.  The  various 
divisions  into  which  the  department  is  organized  indicate  the  range 
of  its  work. 

The  Bureau  of  Vital  Statistics  gives  a  knowledge  of  existing  dis- 
eases which  should  and  can  be  combated :  it  has  a  personnel  of  twenty- 
five  to  thirty,  and  a  series  of  1,070  local  registrars,  each  with  a 
deputy.  The  Division  of  Medical  Inspection  which  carries  on  public 
health  activities  in  the  small  towns  has  a  personnel  of  approximately 
800,  in  addition  to  921  school  medical  inspectors,  whose  importance  is 
later  discussed.  The  Division  of  Sanitary  Engineering  advises  on 
water  and  sewage  systems  and  prevents  pollution  of  water  supplies, 
employing  a  staff  of  106.  The  Division  of  Laboratories  and  the  Dis- 
tribution of  Biological  Products,  makes  analyses  for  physicians  and 
supplies  them  with  various  serums.  A  recently  created  Bureau  of 
Housing  was  inactive  in  1913-1915  because  no  funds  were  appro- 
priated for  it,  but  since  that  time  has  been  actively  organized.  The 
Divisions  of  Tuberculosis  Sanitoria  and  Dispensaries  do  exceedingly 
important  preventive  work  through  the  three  State  Tuberculosis 
Sanitoria  at  Cresson,  Mont  Alto  and  Hamburg,  and  through  119 
tuberculosis  dispensaries,  employing  200  physicians  and  119  nurses. 
The  work  of  these  nurses  includes  not  only  the  prevention  and  care  of 
tuberculosis,  but  also  Child  Welfare  and  Health  Work  in  general  in 
the  homes  of  tuberculosis  patients.  Milk,  eggs  and  other  forms  of 
charitable  relief  are  furnished  to  needy  patients,  and  follow-up  sys- 
tems are  maintained.  The  tuberculosis  work  is  perhaps  the  most 
important  work  of  the  State  Department. 

A  similar  chain  of  dispensaries  for  the  treatment  of  venereal  dis- 
ease is  now  being  established  by  the  Division  for  the  Treatment  of 
Veneral  Diseases. 


205 

There  is  also  a  Division  for  the  Control  of  the  Sale  of  Narcotics, 
and  a  Division  of  Public  Service,  which  attempts  to  maintain  sani- 
tary standards  in  hotels,  restaurants,  and  other  places  where  food  is 
sold. 

The  Division  of  Child  Hygiene  is  organized  to  work  for  the  lower- 
ing of  infant  mortality  in  the  state,  and  has  a  staff  of  five  nurses  for 
the  state,  exclusive  of  Philadelphia,  to  assist  communities  in  estab- 
lishing child  welfare  activities.  The  State  Department  of  Health 
alone  estimates  that  it  saved  60,000  lives  between  1906  and  1914. 

Noteworthy  as  are  the^e  results,  the  Health  Department  itself 
would  be  the  first  to  acknowledge  that  it  does  not  touch  the  greater 
part  of  existing  sickness  or  adequately  meet  the  problem  of  its  pre- 
vention. Dr.  Wilmer  R.  Batt,  chief  of  the  Bureau  of  Vital  Statistics, 
as  has  been  previously  stated,  gives  as  "the  adopted  field  of  public 
health  activities,"  "the  acute  communicable  diseases  of  epidemic 
type"  (including  tuberculosis),  and  the  diseases  of  infants.  In  1915, 
these  diseases  accounted  for  somewhat  less  than  a  third  of  the  deaths 
in  Pennsylvania  in  that  year.  Even  within  the  field  of  public  health 
work,  many  local  health  departments  are  ineffective  or  fail  to  act, 
especially  in  the  smaller  towns.  The  State  Health  Department,  in 
discussing  the  health  work  of  the  boroughs,  in  which  live  2,225,000  of 
the  population  of  the  state,  enumerated  as  handicaps  the  difficulty  of 
getting  competent  citizens  of  good  standing  to  serve,  the  jealousy  of 
such  bodies  as  school  boards  and  borough  councils,  failure  to  enforce 
quarantine  according  to  the  rules  of  the  state,  especially  where  there 
are  only  a  few  cases  of  disease,  and  laxity  in  attending  to  such  nuis- 
ances as  poor  housing  and  the  improper  disposal  of  garbage  and 
sewage.  The  difficulty  of  obtaining  sufficient  appropriations,  also 
mentioned,  is  not  confined  to  the  boroughs. 

All  the  limitations  and  many  others  were  emphasized  in  recent 
surveys  made  under  the  supervision  of  the  Division  of  Child  Hygiene 
of  the  State  Department  of  Health.  Of  fourteen  communities  studied 
only  three  had  active  local  boards  of  health  or  health  officers.  These 
communities  ranged  from  1,200  to  35,000  in  population,  and  several 
of  them  were  important  industrial  centers.  The  large  percentage  of 
foreigners  in  almost  all  of  them  made  doubly  necessary  active  health 
work  and  the  enforcement  of  sanitary  laws.  Yet  in  only  two  of  the 
communities  were  contagious  diseases  carefully  reported.  In  eight 
out  of  the  fourteen,  the  housing  and  general  sanitary  conditions  were 
reported  as  very  serious.  In  one  city  of  over  30,000  the  garbage 
collection  depended  entirely  upon  volunteers,  and  children  often 
gathered  it  in  open  express  wagons.  The  housing  conditions  showed 
extreme  over-crowding  in  the  industrial  centers,  and  in  the  rural 
communities  many  of  the  problems  were  even  more  serious — water 
standing  in  cellars,  old  houses  in  bad  need  of  repair,  and  wholly 


206 

improper  facilities  for  the  disposal  of  waste.  In  one  mining  com- 
munity where  more  than  two-thirds  of  the  population  of  16,000  were 
foreigners,  the  infant  death  rate  in  1917  was  177  per  1,000.  From 
one-third  to  one-half  of  the  school  children  were  undernourished,  the 
number  of  premature  and  still  births  was  above  the  average,  yet 
there  was  no  infant  welfare  or  prenatal  work,  contagious  diseases 
were  not  reported,  garbage  was  deposited  on  a  dump,  sewage  was 
carried  off  in  an  open  sewer,  and  the  Board  of  Health  was  purely 
a  "nominal  body." 

In  another  instance  where  a  still  larger  proportion  of  the  com- 
munity were  foreign^^s,  it  was  reported  that  from  1,100  to  1,300 
children  were  born  every  year,  and  that  three  out  of  every  five  of  these 
children  died  under  five  years  of  age.  The  housing  conditions  in 
this  community  were  rated  as  the  worst  in  Pennsylvania.  No  build- 
ing, plumbing,  or  milk  inspection  was  made.  The  appropriation  for 
health  work  was  |1,200,  while  the  population  was  approximately 
35,000.  The  percentage  of  illiteracy  among  the  men  of  voting  age 
in  this  community  was  28.6,  the  highest  rate  for  any  city  of  similar 
size  in  the  state. 

In  many  instances  what  sanitary  laws  were  found,  were  not  en- 
forced. A  laxity  in  the  enforcement  of  school  attendance,  bad  sani- 
tary and  housing  conditions,  lack  of  nursing  and  hospital  facilities, 
and  high  death  rates,  went  hand  in  hand.  Four  communities  had 
no  appropriations  whatsoever  for  health  work.  Several  had  health 
oflScers  who  were  not  in  any  way  qualified.  The  salaries  of  these 
officers,  sometimes  as  low  as  |500.00  a  year,  did  not  permit  efficiency 
or  enforcement.  The  State  Department  of  Health  attributes  the 
high  mortality  rate  in  these  communities  to  the  (1)  poor  housing, 
(2)  insanitary  conditions  of  streets  and  alleys,  (3)  failure  to  report 
contagious  diseases,  (4)  lack  of  infant  welfare  and  prenatal  work 
(5)  improper  feeding  of  infants,  because  of  the  poor  milk  supply 
and  patent  mixtures,  (6)  failure  to  call  a  physician  (especially  among 
foreign  families),  except  in  extreme  cases,  and  (7)  very  improper 
care  at  confinement  because  of  unregistered  midwives  and  inexperi- 
enced neighbors  or  friends. 

For  many  of  these  conditions  the  community  is  directly  respon- 
sible. Yet  outside  the  largest  cities  it  is  the  exceptional  place  which 
has  even  a  full  time  health  officer,  much  less  an  adequate  health 
appropriation.  The  American  Public  Health  Association  claims  that 
a  dollar  per  person  a  year  would  be  the  desirable  amount  for  public 
health  work.  The  state's  largest  city,  Philadelphia,  had  an  appro- 
priation in  1917  of  10.46  per  capita,  and  in  1918  of  |0.42.  In  at- 
tempting to  save  money  lives  are  resklessly  lost,  for  in  the  absence 
of  adequate  funds,  public  health  work  must  fail  to  exercise  its  due 
preventive  effect  even  within  its  adopted  field. 


207 

Perhaps  the  most  significant  available  material  on  sickness  pre- 
vention in  this  state  is  the  material  on  the  medical  inspection  of 
school  children.  In  considering  prevention  we  instinctively  turn  to 
infant  and  child  welfare  work.  The  men  rejected  in  the  draft  as 
physically  unfit  were  the  school  children  of  yesterday,  and  if  their 
defects  had  been  treated  earlier  they  might  not  have  been  disquali- 
fied. Dr.  Frederick  Peterson  of  the  National  Education  Association 
said  recently,  "Authorities  show  us  that  there  are  physical  defects  in 
75  per  cent,  of  the  school  children  of  to-day,  most  of  them  preventable 
and  remediable,  heart-and-lung-diseases,  disorders  of  hearing  and 
vision,  malnutrition,  diseased  adenoids  and  tonsils,  flatfoot,  weak 
spines,  imperfect  teeth —  ♦  *  ♦  ♦  compulsory  education  we  have — 
compulsory  feeding  and  training  of  the  mind.  Compulsory  health 
we  must  have — compulsory  feeding  and  training  of  the  body."^ 

In  Pennsylvania  medical  inspection  of  school  children  is  compul- 
sory only  for  the  first  and  second  class  districts.  For  the  third  and 
fourth  class  districts,  that  is  for  districts  having  a  population  of 
5  000  to  30,000  and  of  5,000  or  less,  inspection  is  optional,  but  a 
definite  vote  declining  it  is  necessary,  and  few  school  boards  take 
this  action.  The  result  is  that  in  1918  of  2,589  school  districts  in 
the  state,  there  was  medical  inspection  in  2,437,  or  almost  94  per 
cent.    The  districts  were  divided  as  follows: 

4th  class,   2,382  Medical  inspection  in  2,321 

3rd  class,  191  Medical  inspection  in     lOO 

2nd  class,  14  Medical  inspection  in       14 

1st  class,    2  Medical  inspection  in         2 

Total.     1,589       Medical  inspection  in  2,437 

When  medical  supervision  in  schools  was  first  introduced  into 
the  United  States  some  twenty  years  ago,  the  primary  purpose  was 
a  desire  to  reduce  the  acute  communicable  diseases.  Since  then  the 
conception  of  what  preventive  work  may  accomplish  has  greatly 
extended  the  field  of  this  health  activity.  "Although  lessening  of 
communicable  disease  is  necessary  to  be  kept  in  mind  while  per- 
forming the  work,  by  far  the  most  important  phases  of  medical  super- 
vision are  those  dealing  with  the  broad  problems  of  school  hygiene 
by  practical  teaching  and  by  medical  inspection  of  the  individual 
pupil  and  the  giving  of  proper  advice  or  treatment  to  those  found 
defective;  this  may  be  carried  even  to  the  segregation  of  certain 

oups  of  diseased  children  while  continuing  their  school  work;  to 
providing  separate  schools  for  the  defective)  and  incorrigible;  to 
providing  free  medicine  or  dental  care  to  the  poor;  to  surrounding 
the  child  with  proper  sanitary  precautions  in  buildings  and  grounds, 
with  a  safe  water  supply;  and  in  some  instances  even  to  supply 
proper  nourishment."^ 

(>)LiteMry  Digest,   October  12,   1918,  page  20. 

(2)Report  on  Social  Medical  Supervision,  Washington,  D.   C,   1914. 

14 


^5 


208 

From  the  time  of  the  passage  of  the  School  Code  in  1911,  the  growth 
of  School  Medical  Inspection  in  the  fourth  class  districts  of  the  state 
is  significant: 


School  Year. 

Districts 
Inspected. 

School  Buildings 
Inspected. 

Pupils 
Inspected. 

1912-13 - 

1913-14,    _ 

767 
1,469 
1,831 
2,159 

8,572 

7.375 

8,969 

11,036 

145,499 

305.372 
344.099 
469.199 

1,311,603 

During  this  four  year  period  in  the  fourth  class  districts  about  a 
million  and  a  quarter  children  have  been  examined;  of  the  469,199 
examined  in  1914-15,  335,427  or  71.5  per  cent,  were  found  to  be  de- 
fective. Of  these  44  per  cent,  had  multiple  defects.  In  the  third 
class  districts  where  48J87  pupils  in  21  counties  were  inspected, 
33,552,  or  68.8  per  cent,  were  found  to  be  defective.  The  National 
Education  Association  after  a  survey  in  1914  of  country  school  con- 
ditions, came  to  the  conclusion  that  wherever  urban  and  rural  statis- 
tics were  contrasted,  the  country  child  was  found  to  be  from  five  to 
twenty  per  cent,  more  defective  than  the  city  child.  In  Pennsylvania 
they  estimated  that  75  per  cent,  of  the  children  were  defective  in  the 
rural  population  of  a  given  county.  Among  the  school  children  in 
Altoona  and  Pittsburgh,  the  per  cent,  of  defectives  foF  the  same  year 
was  69  and  72  per  cent.,  respectively. 

The  powers  exercised  by  the  Health  and  School  authorities  are 
purely  recommendatory,  with  the  exception  of  the  segregation  of 
communicable  diseases.  Notes  are  sent  through  the  teacher  to  the 
parents  of  defective  children,  giving  advice  as  to  treatment.  In 
fourth  class  districts  in  1914-15,  90.8  per  cent,  of  the  children  having 
defects  received  these  letters  of  advice.  More  than  51  per  cent,  of 
those  examined  had  been  followed  through  the  year,  but  only  22  per 
cent,  of  these  were  getting  some  sort  of  treatment.  An  examination 
of  the  nature  of  the  defects  in  the  pupils  examined  brought  out  the 
fact  that  the  large  majority  are  easily  correctable  if  treated  in  time. 
Eyes,  tonsils  and  teeth  can  all  be  remedied  if  the  treatment  is  given 
early,  and  they  account  for  the  largest  numbers  of  defects. 


209 

NATURE  OF  DEFECTS.i 


Per  Cent,  of 
Total  Pupils 
Examined. 

Number  of  pupils  with  defective  vision, 83,748  17.8  % 

1  eye,  27,834 

2  eyes,  1 55,814 

Number  with  other  eye  aflBictions, 5,512  1.64% 

(Conjunctivitis,  iritis,  trachoma,  astigmatism,  etc.) 

Number  with  defective  hearing,  15,600  3.3  % 

Number  with  defective  breathing,  22,837  4.9  % 

(Of    these,    6,713    or    more   than    25%   were    "suspected"    of    having 
adenoids.) 

Number  with  defective  teeth,  252,174  53.7  % 

(Of  these,  45.3%  had  decayed  teeth.) 

Number  with  enlarged  tonsils,  123,222  26.3% 

Number  with  enlarged  cervical  glands,  22,874  4.9  % 

Number  with  tuberculosis, 789  .17% 

Number  with  nervous  diseases, 755  .16% 

Number  with  skin  diseases, 6,296  1.3  % 

Number  with  malnutrition 8,578  1.8  % 

Number  with  deformities, -.  1,645              

Number  with  quarantinable  diseases, 56  .04% 

Of  those  having  more  than  one  defect,  54,225,  or  more  than  36  per 
cent,  had  defective  tonsils  and  teeth. 

The  result  of  treatment  on  these  correctable  defects  is  easily  seen. 

Of  the  10,041  cases  of  defective  vision  treated,  6,899,  or  68.7  per 
cent,  were  improved. 

Of  the  1,321  cases  of  defective  hearing  treated,  762,  or  57.6  per 
cent,  were  improved. 

Of  the  1,190  cases  of  defective  breathing  treated,  724  or  60.8  per 
cent,  were  improved. 

Of  the  45,119  cases  of  defective  teeth  treated,  45,119  or  100  per 
cent,  were  improved. 

Of  the  6,844  cases  of  defective  tonsils  treated,  4,373  or  63.8  per 
cent,  were  improved. 

Of  the  150  cases  of  defective  skin  diseases  treated,  116,  or  77.2  per 
cent,  were  improved. 

Of  the  178  cases  of  malnutrition  treated,  107,  or  60.1  per  cent  were 
improved. 

In  spite  of  the  fact  that  so  small  a  proportion  of  the  total  number 
of  defective  children — only  16.3  per  cent  really  secure  treatment,  the 
reduction  in  the  number  of  defective  pupils  is  decreasing  materially 
every  year.  In  1911-12,  76.7  per  cent  of  those  examined  were  found 
to  be  defective.  In  1914-15  this  had  fallen  to  71.5  per  cent.  The 
number  of  pupils  with  defective  tonsils  has  been  reduced  from  35.1 
per  cent  to  26.2  per  cent;  with  defective  vision,  from  29.  per  cent 
to  17.8  per  cent. 


Total  number  inspected, 

Per  cent,  of  defective  pupils,  

Per  cent,  of  pupils  with  defective  vision, 

Per  cent,  of  pupils  with  defective  hearing,  

Per  cent,  of  pupils  with  defective  nasal  breathing 
Per  cent,  of  pupils  with  enlarged  cervical  glands, 
Per  cent,  of  pupils  with  defective  tonsils, 


1911-12. 

1912-13. 

1913-14. 

145,499 

305,372 

377,079 

76.7 

74.9 

72.7 

29.0 

27.0 

24.2 

3.4 

2.9 

3.3 

10.8 

3.4 

5.7 

8.7 

6.9 

5.9 

35.1 

28.5 

23.0 

469,199 

71.5 

17.8 

3.3 

4.9 

4.9 

26.2 


(1)  Department  of  Health,  9th  Annual  Report,  1914,  Part  I. 


210 

A  large  part  of  this  reduction,  especially  of  defects  of  vision,  is 
due  to  the  educational  work  instigated  by  the  State  Department  of 
Health  and  the  various  societies  throughout  these  districts.  Tooth- 
brush drills,  health  charts,  and  the  proper  teaching  of  hygiene,  can 
but  produce  significant  results. 

The  activities  of  the  School  Medical  Inspectors  in  these  4th  class 
districts  have  not  been  confined  solely  to  the  medical  examination  of 
the  children.  Sanitary  inspection  of  the  school  buildings  has  been 
instituted,  and  by  notifying  school  boards  of  bad  conditions  and 
suggesting  possible  remedies,  insanitary  conditions  in  these  build- 
ings have  materially  improved.  In  1914-15,  2,353  out  of  the  2,377 
4th  class  districts  were  inspected.  The  12,525  buildings  inspected 
contained  19,892  rooms.  Ninety-eight  and  five  tenths  per  cent  of 
these  buildings  were  insanitary  in  one  or  more  points. 


No  adjustable  seats  or  foot  stools,  ___    70.e%  of  the  buildings. 

Unjaeketed  stoves,   38.6%  of  the  buildings. 

No  thermometers, 37.3%  of  the  buildings. 

No  provision  to  keep  air  moist,  63.8%  of  the  buildings. 

No  fresh  air  inlets  at  stove  or  ftirnace,  67.8%  of  the  buildings. 

Windows  only  ventilation,    ^_  74.4%  of  the  buildings. 

Ventilation  shields  not  in  use,  56.1%  of  the  buildings. 

Insanitary  water  container.   — 25.1%  of  the  buildings. 

Common  drinking  cup,   37.2%  of  the  buildings. 

Common   tcwel,    38.4%  of  the  buildings. 

Privies  unclean,    22.5%  of  the  buildings. 

Pri«ies  improperly  built,    51.2%  of  the  buildings. 

Vaults  insanitary,  71.8%  of  the  buildings. 

No  disinfectant  used,   49.1%  of  the  buildings. 


The  light  area  in  42.1  per  cent  of  the  rooms  was  judged  insufficient. 
The  relation  between  this  insanitary  environment  and  the  fact  that 
almost  three-fourths  ^f  our  country  school  children  have  physical 
defects,  is  obvious. 

Standards  \)f  inspection  were  raised  with  distinct  improvemenfs 
noted  during  the  year.  Insanitary  sweeping  was  reduced  from  (>() 
to  51  per  cent.  Insanitary  dusting  was  reduced  from  43  to  32  per 
cent.  Insanitary  w^ater  containers  were  reduced  from  37  to  25  per 
cent.  Insanitary  cleaning  of  the  water  containers  was  reduced  from 
50  to  44  per  cent. 

More  recent  figures  on  school  medical  inspection  are  available  for 
Philadelphia.  In  1916,  151,869  pupils  were  examined  or  about  75 
per  cent  of  the  total  number  of  school  children.  The  city  Depart- 
ment of  Health  has  never  had  the  necessary  facilities  for  fully  carry- 
ing out  the  law^,  and  examining  all  school  children.  One  hundred  and 
sixty-seven  thousand,  two  hundred  and  sixty-nine  defects  were  rec- 
ommended for  treatment. 

The  majority  of  the  defects  found  in  these  children,  like  iho^o 
found  in  the  school  children  of  the  4th  class  districts  of  the  stale, 
are  correctable. 


211 

DEFECTS  RECOMMENDED  FOR  TREATMENT. 

Philadelphia  School  Children,   1915-16. 


Eye,   

Nose,  throat,  mouth, 

Ear,    ^ 

Teeth.    ___i 

Orthopedic, 

Nutrition,    

Heart,   

Nervous  diseases,  

Defective  mentality,  

Grastro-intestinal,    

Skin,    

Acute  illness  and  accidents, 


Per  Cent. 

of  Total. 

21,960 

13.1  % 

28,401 

16.9  % 

1'.681 

1.04% 

76,923 

45.9  % 

3,132 

1.8% 

3,222 

1.9% 

883 

568 

260 

21 



25,313 

15.1  % 

2,865 

T.7  % 

"Poor  nutrition  and  eye  strain  are  the  two  basic  and  original  de- 
fects, and  the  niajorit}^  of  the  physical  defects  of  later  childhood  are 
secondary  defects  resulting  from  neglect  of  these."^  For  example, 
chronic  heart  disease  is  often  the  result  of  acute  infections  like 
tonsillitis  or  influenza  and  defective  hearing  is  often  the  result  of 
adenoids,  which  in  turn,  can  be  traced  in  many  cases  to  poor 
nutrition. 

''Some  of  the  figures  given  are  too  low,  because  in  the  poorer  sec- 
tions of  the  city  the  inspectors  become  dulled  to  the  existence  of 
poor  nutrition  in  its  moderate  degree,  and  because  care  is  possible 
o*ily  by  impossible  changes  in  the  homes.  The  number  of  stoop- 
shouldered  children  recorded  is  likewise  too  small,  because  the  lack 
of  facilities  for  corrective  work  has  tended  to  make  the  inspectors 
overlook  mild  cases.  In  1917,  with  the  institution  of  corrective 
gymnastics,  there  will  be  over  10,000  stoop-shouldered  children 
nominated  for  corrective  exercises  by  medical  inspectors.  The  items 
chorea,  constipation,  appendicitis,  etc.,  represent  chance  discoveries 
and  emergency  cases,  rather  than  comprehensive  and  thorough  exam- 
inations of  pai'ts  of  the  body."^ 

Many  factors  influence  the  correction  of  these  defects.  The  most 
important  are  (1)  the  nature  of  the  disease  or  defect,  (2)  the  use  of 
the  school  nurse,  and  (3)  the  attitude  of  the  parents.  In  1916  in 
Philadelphia  149  schools  employed  nurses,  and  fifty-two  did  not.  The 
employment  of  a  school  nurse  almost  doubles  the  efficiency  of  the 
inspector,  and  greatly  increases  the  per  cent,  of  defects  corrected. 
Tlie  percentage  of  physical  defects  corrected  in  1916  varied  from 
33.1  per  cent,  to  43.6  per  cent,  in  schools  where  no  nurse  w^as  em- 
ployed. Where  a  nurse  was  employed,  the  percentages  were  from 
40.5  to  65 — according  to  the  social  grade  of  the  school. 

During  the  last  five  year  period  in  Philadelphia  the  percentage  of 
cases  receiving  treatment  has  constantly  increased. 

In  1912  only  45  per  cent,  of  the  cases  recommended  for  treatment 
received  it,  while  in  1916  this  percentage  had  increased  to  54.9.     In 


(1)  Annual  Report,  Bureau  of  Health,  Philadelphia,  1916,  pages  31  and  36. 
(2) Annual  Report,  Bureau  of  Health,  Philadelphia,  1916,  page  36. 


212 

the  treatment  of  "important  defects"  the  increase  has  been  from  31 .4 
to  43.8  per  cent.;  in  the  treatment  of  "unimportant  defects"  from 
85.5  to  95.3  per  cent. 

Of  the  54.9  per  cent,  receiving  treatment,  33.9  per  cent,  were  treated 
through  a  private  physician,  22.5  per  cent  through  a  dispensary,  12.1 
per  cent,  through  a  nurse,  31  per  cent,  through  the  parents,  land  0.5 
per  cent,  through  the  medical  inspector.  It  is  significant  that  in 
the  analysis  of  the  type  of  treatment  received,  the  number  of  defects 
treated  through  a  dispensary  increases  steadily  and  the  number 
treated  through  a  private  physician  decreases,  as  the  social  grade  of 
the  school  is  lowered.  Thus  in  1916  in  schools  of  Social  Grade  A,  60.3 
per  cent,  of  the  defects  were  treated  by  a  physician,  and  17.2  by  a 
free  dispensary.  In  schools  of  Social  Grade  C,  only  22  per  cent, 
were  treated  by  private  physicians  while  25.6  per  cent,  obtained  care 
through  free  dispensaries. 

In  the  case  of  the  45  per  cent,  of  the  defective  children  who  re- 
ceived no  treatment,  in  78  per  cent,  of  the  cases,  the  non-treatment 
was  due  to  the  refusal  of  the  parents.  Poverty  and  ignorance  play  a 
large  part  here,  as  well  as  the  lack  of  dispensary  facilities.  The  re- 
sults of  the  treatment,  where  it  was  secured,  show  without  question 
the  need  for  further  and  more  complete  medical  inspection.  Of 
some  76,045  cases  of  defects  in  schools  employing  nurses  where  the 
results  of  treatment  were  examined,  it  was  found  that  in  only  2.6 
per  cent,  there  was  no  marked  improvement.  In  71.7  per  cent,  the 
defect  had  been  cured  and  in  25.8  per  cent,  it  had  been  materially 
improved.  Considering  the  "important  defects"  separately,  we  find 
that  more  than  61  per  cent,  were  cured  and  more  than  34  per  cent, 
were  improved. 

These  figures  speak  for  themselves.  When  we  go  behind  the  school 
children. to  the  babies  we  find  the  need  of  measures  for  sickness  pre- 
vention still  more  urgent.  The  startling  infant  mortality  rates  in 
this  state  have  been  discussed  at  length  in  Part  II,  Section  I.  The 
need  for  maternity  care  was  brought  out  in  every  survey  made.  "As 
the  twig  is  bent,  so  is  the  tree  inclined." 

The  question  is,  how  to  stimulate  a  more  general  and  more  ex- 
tensive movement  for  disease  prevention. 

The  state  has  a  definite  responsibility  in  seeing  to  it  that  some 
action  is  taken  both  to  more  adequately  treat  actual  sickness  and 
to  prevent  it  by  an  attack  upon  its  causes.  The  state  alone  has  the 
power  to  act  in  a  way  which  will  be  far  reaching  and  democratic; 
which  will  not  limit  the  solution  to  the  chosen  few  of  an  individual 
group. 

Among  proposals  for  aiding  in  this  solution  stands  State  Health 
Insurance,  claiming  to  provide  care  for  employees  when  ill,  and  to 
stimulate  sickness  prevention  and  keep  them  well. 


213 

Any  insurance  plan,  as  a  matter  of  business  efficiency,  must  pro- 
vide and  further  preventive  measures;  Health  Insurance  and  pro- 
grams for  sickness  prevention  are  not  opposed  in  any  way  to  each 
other.    Neither  takes  the  place  of  the  other,  and  both  are  necessary. 

Advocates  of  social  insurance  claim  that  nothing  so  quickly  stimu- 
lates preventive  effort  as  the  enactment  of  insurance  laws.  Two 
reasons  appear  for  this  stimulus  to  prevention  created  by  insurance. 
One  is  the  desire  of  the  insurance  organization  to  reduce  its  losses. 
The  other  is  the  desire  of  the  persons  paying  for  insurance  to  reduce 
the  cost. 

Dr.  I.  M.  Rubinow,  one  of  the  leading  American  students  of  social 
insuraiice^lEas  recently  given  a  clear  description  of  these  preventive 
forces,  enumerating  the  different  kinds  of  "preventive  work  carried 
on  because  of  insurance." 

"Not  only  have  the  insurance  organizations  of  various  types 
worked  for  prevention  and  reduction  of  losses,  but  they  have  also  en- 
deavored to  obtain  the  co-operation  of  the  insured  in  exercising  better 
care,  while  relieving  him  of  the  fear  of  loss;  they  have  introduced 
another  motive  through  the  mechanism  of  premium  adjustment."^ 
Fire  insurance  has  resulted  in  stricter  building  laws,  in  better  fire 
extinguishing  facilities,  in  the  development  of  automatic  sprinklers ; 
Commercial  Life  Insurance  Companies  have  found  it  to  their  ad- 
vantage to  establish  and  encourage  public  health  nursing  and  life- 
extension  movements;  compensation  insurance  has  given  a  tremen- 
dous stimulus  to  industrial  safety;  health  insurance  in  Europe  has 
stimulated  better  care  of  the  sick  and  convalescent,  and  unemploy- 
ment insurance  has  stimulated  better  provision  for  public  employ- 
ment offices. 

If  State  Health  Insurance  gives  promise  of  stimulating  adequate 
measures  for  sickness  prevention,  and  so  making  possible  the  elimi- 
nation of  from  40  to  60  per  cent,  of  existing  illness,  while  at  the 
time  it  makes  provision  for  the  treatment  of  that  large  part  of  the 
I>opulation  which  will  continue  to  suffer  from  the  burden  of  sick- 
ness, it  is  worthy  of  thorough  study  and  careful  consideration. 

From  all  the  statistics  gathered  and  special  studies  made  it  is 
startlingly  evident  that  some  far-reaching  measures  are  needed  in 
Pennsylvania,  both  for  the  efficient  care  of  employees  and  their 
families  when  actually  ill  and  also  for  the  prevention  of  disease,  if 
this  state  is  to  fulfill  its  great  responsibility  to  the  citizenship  of 
the  future. 

Any  constructive  action  which  the  Commission  can  take  to  meet 
these  needs  will  be  a  direct  contribution  to  the  strength  of  the  Com- 
monwealth. 


(^)  I,  M.  Rubinow,  "Prevention  vs.  Insurance,"  The  New  Republic,  July  27,  1918,  page 


M 


(214) 


PART  III. 

Health  Insurance. 


( -nr> ) 


(216) 


217 


PART  III. 

SECTION  I 

Social  Insurance. 

Insurance  is  a  provision  made  by  a  group  of  persons  for  distribut- 
icg  among  themselves  the  losses  which  may  come  to  any  one  of  them 
from  hazards  to  which  they  are  all  subject.  "Insurance  in  all  its 
forms,"  says  Thomas  B.  Love,  Assistant  Secretary  of  the  Treasury, 
"is  the  best  expression  in  organized  business  terms  of  the  great  social 
principle  of  mutuality  and  co-operation."  As  a  distributor  of  risk, 
£ill  insurance  is  social  in  principle,  even  when  conducted  on  a  com- 
mercial basis.  It  removes  from  the  individual  the  anxiety  and  re- 
sponsibility of  the  burden  of  risk  by  allowing  him  to  pay  a  very  small 
share  of  every  man's  loss  in  order  to  have  his  own  loss  distributed 
in  the  same  way.  Owners  of  property,  both  large  and  small,  as  a 
rule,  prefer  the  certain  loss  of  relatively  insignficant  annual 
premiums,  calculated  to  cover  risk,  cost  of  administration  and  busi- 
ness profit  to  the  insurance  carrier,  to  the  chance  of  losing  the  entire 
value  of  their  property.  Fire  and  marine  insurance,  because  of  the 
obvious  nature  of  the  risks  involved,  were  among  the  first  types  of 
such  protection  to  develop.  But  gradually  the  seriousness  of  other 
hazards  was  recognized,  and  systems  for  insuring  lives,  property  and 
business  enterprises  against  every^conceivable  risk  have  been  worked 
out. 

Among  the  more  recent  hazards  to  be  definitely  recognized  and  dis- 
tributed are  those  arising  from  ill  health.  The  realization  of  the  fact 
that  few  workers  by  hand  or  by  brain  can  afford  the  more  or  less  com- 
.plete  loss  of  earning  power  frequently  suffered  from  entirely  unfor- 
seen  attacks  of  illness  has  led  to  the  practice  among  the  more  in- 
telligent and  prosperous  workers  of  carrying  health  insurance  in 
addition  to  life,  accident  or  fire  insurance. 

The  term  "social  insurance"  as  contrasted  with  commercial  insur- 
ance has  come  to  have  a  special  and  distinct  meaning,  both  in  this 
country  and  abroad.  It  is  recognized  that  while  there  are  few  indi- 
viduals with  sufficient  resources  to  meet  alone  the  numerous  risks  to 
which  they  are  subject,  the  wage  earning  classes  of  the  population 
are  peculiarly  subject  to  certain  economic  hazards.  Sickness,  per- 
manent or  temporary  invalidity,  accident,  old  age  and  unemploy- 
ment all  interfere  with  regular  work  and  hence  with  the  steady 
income  necessary  to  maintain  proper  standards  of  living.  Circum- 
stances of  work  and  of  living  for  which  industry  and  the  state  are 


218 

in  a  certain  sense  responsible  make  these  hazards  greater  for  em- 
ployed persons  as  a  class  than  for  others.  Increased  hazards 
mean  higher  premium  rates  for  protection  in  companies  operating  on 
a  commercial  basis,  and  this  fact,  coupled  with  the  frequent  inade- 
quacy of  resources  of  the  exposed  persons,  make  commercial  health, 
accident,  old  age,  or  unemployment  insurance  for  .them  an  impos- 
sibility. 

Not  only  the  workers  themselves,  but  both  industry  and  the  state 
suffer  severely  as  a  result  of  the  industrial  hazards  to  which  em- 
ployed persons  are  subject. 

Kecognizing  these  facts,  organized  society  in  the  form  of  state  gov- 
ernments both  in  Europe  and  in  America  has  in  recent  years  begun 
to  distribute  the  risk  among  the  three  factors  responsible  for  and 
exposed  to  it,  employees,  employers  and  the  state.  This  has  been 
done  by  the  regulation  of  insurance  carriers  and  the  elimination  of 
profit,  thus  reducing  the  premium  rate,  by  the  assumption  of  a  part 
of  the  cost  of  administration,  by  imposing  upon  the  employing  class 
a  share  in  the  cost,  and  by  compelling  the  wage  earner  to  contribute 
his  share. 

The  only  general  experience  with  social  insurance  in  the  United 
States  is  in  the  field  of  Workmen's  Compensation,  but  in  Europe 
almost  universal  provision  has  been  made  to  meet  the  problems  of 
siqkness,  old  age,  invalidity  and  unemploj^ment,  as  well  as  industrial 
accidents  among  wage  workers,  by  systems  of  social  insurance.  In 
some  cases  these  systems  are  voluntary,  regulated  and  subsidized  by 
the  state,  but  they  are  rapidly  being  replaced  by  compulsory  social 
insurance  acts. 


¥ 


219 

PART  III. 

SECTION  II. 

Health  Insurance  in  Europe.^ 

Health  Insurance  in  some  form  or  other  has  been  in  existence  in 
Europe  almost  since  the  beginning  of  wage  employment  itself.  Long 
before  the  political  development  of  state  insurance  systems,  mutual 
insurance  against  sickness  was  being  administered  by  the  many  sick 
benefit  societies  originated  by  the  wage-workers  themselves  as  an 
attempt  to  distribute  risks. 

These  original  societies  were  of  several  kinds: 

1 — Private  mutual  societies  composed  of  persons  of  various 
occupations.  These  were  usually  local  in  character  and  at- 
tempted to  maintain  more  or  less  complete  systems  of  insur- 
ance. In  France  and  Belgium  great  emphasis  was  laid  on 
^annuities,  but  sick  benefits  gradually  assumed  importance  in 
all  countries.  The  chief  features  of  these  benefits  were  medi- 
cal care  and  hospital  care,  medicines,  and  cash  benefits  for 
members,  medical  care  and  sometimes  cash  benefits  for  the 
families  of  members,  and  lump  sums  paid  at  times  of  con- 
finement. 

,  Few  of  these  societies  accumulated  a  sufficient  reserve  to 
insure  actuarial  solvency,  and  almost  none  of  them  adjusted 
their  dues  to  meet  the  increasing  hazards  due  to  the  advanc- 
ing age  of  their  members.  Consequently,  financial  ruin  was 
a  constant  danger. 
2 — Federated  or  affiliated  societies  grew  out  of  the  combining 
of  many  of  the  local  bodies.  Meetings  were  held  regularly, 
and  rituals  were  gradually  developed.  This  form  of  lodge 
organization  exists  to-day  in  thousands  of  fraternal  societies 
all  over  the  world.  Some  of  these  affiliated  societies  grew 
to  enormous  size,  especially  in  England,  and  administered 
both  life  insurance  and  health  insurance.  Scarcely  any  of 
them  however,  were  solvent,  as  a  whole.  In  England  in  1909, 
before  the  passage  of  the  National  Health  Insurance  Act, 
the  Manchester  Unity  of  Odd  Fellows  and  the  Ancient  Order 
of  Foresters  had  each  about  1,000,000  members,  and  a  large 
number  of  lodges,  but  in  both  of  them  the  insolvency  of  some 
of  the  branches  more  than  offset  the  flourishing  condition  of 
others. 
3 — Establishment  societies  among  the  employees  of  individual 
establishments  or  businesses  and  frequently  supported  in 
part  by  the  employers  were  also  formed  for  the  administra 
tion  of  sick  benefits.  Membership  in  some  of  these  fu 
was  required  by  the  employer,  while  in  other  cases  it 


(»)See  Tables  I  and  II  at  end  of  Part  in. 


itra-    JMm- 

w 


220 

voluntary.  The  influence  of  the  employer  seems  to  have 
been  the  chief  difficulty  in  these  funds.  Employers  of  course 
used  their  influence  with  varying  motives.  In  some  cases 
the  organization  of  employees  in  the  funds  was  used  to  pre- 
vent the  formation  of  labor  unions  among  them,  and  often 
the  mobility  of  labor  was  interfered  with,  for  employees 
were  usually  unwilling  to  leave  funds  to  which  they  had 
contributed  and  from  which  they  had  not  received  benefits, 
unless  their  contributions  could  be  refunded  to  them. 
4— Trade  Unions  began  at  an  early  period  to  include  the  pay- 
ment of  sick  benefits  among  their  other  activities.  They 
almost  invariably  failed  to  provide  for  solvency,  however, 
making  no  adjustment  of  rates  to  correspond  to  the  increas- 
ing risks  of  advancing  age,  and  not  attempting  to  maintain 
reserves  sufficient  to  assure  the  payment  of  claims  perman- 
ently. The  constant  admission  of  young  men  to  membership 
helped  to  stabilize  the  risk,  but  the  rate  of  increase  in  mem- 
bership was  largely  dependent  on  the  ability  of  the  Unions 
to  improve  industrial  conditions,  and  showed  wide  fluctua- 
tions. 
VOLUNTARY  HEALTH  INSURANCE  SUBSIDIZED  BY  THE  STATE. 

Realization  of  the  benefits  to  be  secured  from  these  insurance 
schemes,  and  of  the  financial  difficulties  confronting  them  has  led 
various  European  governments  to  encourage  their  growth  by  grant- 
ing subsidies  to  certain  societies  which  conform  to  specified  stand- 
ards. "It  has  been  a  noticeable  feature  in  the  subsidized  state  in- 
surance schemes  that  the  rapidity  and  energy  of  their  growth  seems 
to  have  been  in  ratio  to  the  subsidies  obtained  from  the  state.  With- 
out state  aid,  only  the  more  thrifty  and  well  paid  of  the  workers 
seem  voluntarily  to  insure,  and  many  of  these  often  are  unable  to 
keep  up  their  insurance  and  drop  it.  As  long  as  the  state  held 
aloof  and  simply  exercised  control  without  giving  assistance,  the 
growth  of  this  voluntary  insurance  has  always  been  slow.  The  more 
the  state  has  given  assistance,  the  greater  hvs  been  the  mnnber  of 
'  workmen  who  have  been  able  to  secure  the  protection  they  seek."^ 

DENMARK. 
The  system  of  voluntary  subsidized  health  insurance  in  operation 
in  Denmark  has  remained  practically  unchanged     for    more    than 
twenty-five  years,  and  is  an  interesting  example  of  this  method. 

After  thirty  years  of  investigation  and  discussion,  the  present  law 
was  %j,opted  on  April  12,  1892. 

investigations  of  sick  benefit  societies  by  governmental  Com- 
^ssions  had  revealed  the  fact  that  the  1,000  societies  in  existence 
,^%st  before  the  passage  of  the  law  had  a  combined  membership  not 

(*) American  Medical  Association — Social  Insurance  Series,    Pamphlet  11,   page  10. 


221 

exceeding  eight  per  cent,  of  the  population,  that  less  than  one-third 
of  the  societies  furnished  both  money  benefits  and  medicaLaid,  and 
that  the  amount  of  benefit  was  usually  very  small,  in  some  districts 
as  low  as  one-quarter  krone  (less  than  seven  cents)  a  day. 

As  first  drafted,  the  law  of  1892  provided  for  compulsory  health 
insurance,  but,  after  prolonged  discussion,  the  principle  of  subsidies, 
combined  with  regulation,  was  substituted  for  the  compulsory  prin- 
ciple. The  regulations  to  which  the  societies  must  conform  in  order 
to  secure  the  subsidy  are  very  simple.  Each  society  must  contain  at 
least  fifty  members,  the  maximum  age  limit  being  forty  years,  and 
may  be  organized  either  by  locality  or  by  industry.  The  membership 
must  consist  of  workmen  receiving  small  incomes  or  of  other  persons 
of  similar  economic  condition.  No  person  may  belong  to  more  than 
one  society.  No  medical  examination  is  required  for  admission,  biit 
no  benefits  are  provided  for  chronic  diseases  existing  at  the  time  of 
entrance. 

Certain  minimum  benefits  must  be  given  by  the  societies,  and  cer- 
tain extensions  are  permitted  within  prescribed  limits.  The  required 
benefits  are: 

1 — Free  medical  and  hospital  care  for  members  and  for  their 

children  under  fifteen  who  live  at  home. 
2 — A  cash  sick  benefit  determined  on  the  basis  of  the  sick 
person's  average  wage  for  the  entire  membership.  This 
benefit  must  not  exceed  two-thirds  of  the  normal  wage  of 
the  sick  person  or  fall  below  40  ore  (9.50  cents)  per  day. 
The  usual  range  is  from  11  cents  per  day  for  employees  in 
the  country  to  54  cents  for  those  in  the  city. 

No  benefit  is  paid  for  illness  lasting  less  than  three  days,  and  no 
benefits  are  required  for  normal  confinement  or  pregnancy,  although 
these  may  be  included  voluntarily  by  the  society.  Funeral  benefits 
are  not  allowed  and  the  furnishing  of  drugs  and  supplies  is  optional. 
Societies  may  increase  the  waiting  period,  from  three  to  seven  days, 
and  benefits  to  women  and  minors  may  be  decreased,  while  diseases 
resulting  from  immorality  or  intemperance  may  be  excluded.  The 
minimum  period  during  which  benefits  must  be  furnished  is  thirteen 
weeks. 

The  operation  of  the  law  has  tended  to  increase  materially  the 
membership  in  sick  benefit  societies.  In  1893  there  were  457  reg- 
istered societies  with  a  membership  of  116,763,  while  in  1914  the  1,547 
registered  societies  had  843,244  members,  or  about  30  per  cent,  of 
the  adult  population.  Women  have  for  the  past  several  years  con- 
stituted the  majoritj^  of  tliose  insured. 

Less  than  30  per  cent  of  the  socities  pay  more  than  16  cents  per 
day  to  male  members,  and  less  than  15  per  cent,  pay  as  much  as  16 
cents  per  day  to  women.    About  23  per  cent,  pay  benefits  for  more 


222 

than  thirteen  weeks,  17  per  cent,  having  a  twenty-six  week  period, 
and  three  funds  having  a  longer  period.  Only  about  40  per  cent, 
supply  any  drugs  at  all,  and  only  18  per  cent,  pay  for  the  entire 
cost  of  ordinary  medicine. 

The  state  subsidy  is  apportioned  among  the  societies  in  two  Avays ; 
one-half  is  determined  by  the  membership  at  a  rate  not  to  exceed  two 
kroner  per  member,  and  one-half  by  the  amount  of  dues  collected  from 
members.  This  portion  cannot  exceed  one-fifth  of  the  members'  con- 
tributions. 

Several  communal  governments  also  give  subsidies  to  the  societies 
in  their  districts.  In  1914  these  subsidies  amounted  to  28  per  cent, 
of  the  total  income  of  the  societies. 

INCOME  OF  SICK  BENEFIT   SOCIETIES.i 


Year. 

Membership 
Dues. 

State 
Grant. 

Communal 
Grant. 

All  others. 

Total. 

1895                   _     _    _.- 

$969,083 

1,959,957 

876,899 

1,226,910 

1,745,020 

$410,641 
833,745 
382.0W 
534,407 

741,017 

$34,707 
64,290 
23,121 
36,856 
54,592 

$114,078 
240,747 
64,498 
90,066 
139,631 

$1,528,509 

1900,      .     _ 

3,096,739 

1905 

1,346,582 

1910                                         

1,894,239 

1914-                                           

2,680,620 

In  addition  to  these  money  grants,  the  societies  also  receive  other 
subsidies.  The  communes  are  required  by  the  law  to  treat  members 
of  registe  ed  societies  in  hospitals  at  half  the  regular  rates  and  to 
provide  free  transportation  for  physicians  and  midwives  to  the  homes 
of  members  in  rural  districts. 

The  cost  of  operation  of  the  whole  system  increased  from  |258,07il, 
in  1893,  to  |2,604,400,  in  1914,  or  more  than  nine  fold,  but  so  great 
was  the  increase  in  the  membership  of  the  funds  that  the  average  cost 
per  member  advanced  only  thirty-eight  per  cent,  the  largest  increase 
being  in  the  cost  of  hospital  and  medical  service. 


(1)  Report  of  the  Social  Insurance  Commission  of  Calif omts,  page  20Q, 


223 

PER  CAPITA  COSTi. 


Year. 

Money 
Benefits. 

Hospital. 

Medicine. 

Physician, 

Adminis- 
tration. 

Total. 

Per  Cent. 
Adminis- 
tration 
Cost. 

1893      _.     

$1  01 
1  01 
1  04 

1  02 
93 
93 

$0  12 
14 
18 
27 
31 
39 

$0  28 
28 
31 
34 
32 
33 

$0  62 

77 

88 

99 

1  11 

1  18 

$0  19 
17 
19 
20 
24 
25 

$2  22 
237 
260 
282 

2  91 

3  08 

8.6 

1895.     

7.3 

1900                   

7.8 

1905*,                

7.1 

1910,     

8.2 

1914      

8.1 

The  experience  of  Denmark  with  state  subsidized  health  insurance 
seems  to  indicate  that  to  produce  satisfactory  results  the  subsidy 
must  be  very  substantial  in  amount.  i 

SWITZERLAND. 

Efforts  to  establish  a  comprehensive  insurance  system  in  Switzer- 
land have  covered  a  period  of  forty  years.  After  several  careful  sur- 
veys had  been  made,  a  constitutional  amendment  was  passed  by  the 
Council  and  approved  by  a  referendum  vote  on  October  26,  1890, 
authorizing  the  passage  of  compulsory  insurance  acts.  A  law  provid- 
ing for  compulsory  insurance  against  both  sickness  and  accident  was 
passed  by  the  Council  on  October  2,  1899,  but  rejected  by  a  popular 
referendum  on  May  20,  1900.  In  1906,  after  further  investigation, 
an  act  providing  for  compulsory  accident  insurance  and  a  heavily 
subsidized  system  of  sickness  insurance  was  introduced  into  the 
Council.  It  was  finally  passed  on  June  13,  1911,  and  approved  by 
referendum  vote  on  February  4,  1912. 

This  law  recognized  the  principle  of  compulsory  health  insurance 
by  authorizing  the  different  cantons  and  communes  to  declare  the 
insurance  compulsory  either  generally  or  for  certain  classes  of  per- 
sons, to  establish  public  funds  in  case  they  are  needed,  and  to  compel 
employers  to  attend  to  the  collection  of  the  contributions  of  their 
employees  compulsorily  insured  in  the  public  funds,  without,  how- 
ever, binding  the  employers  themselves  to  the  payment  of  the  con- 
tributions. In  case  the  cantons  or  communes  assume  the  responsi- 
bility of  the  payment  of  all  or  a  part  of  the  contributions  of  indigent 
insured  persons,  the  Confederation  agrees  to  grant  special  subsidies 
to  them  equal  to  one-third  of  their  disbursements. 

As  in  Denmark,  subsidies  are  granted  to  mutual  aid  associations 
under  certain  conditions.  They  must  not  operate  for  profit,  must 
have  their  headquarters  in  Switzerland,  and  must  admit  to  member- 
ship any  Swiss  citizen  who  conforms  to  their  provisions  for  admis- 
sion. Swiss  Citizens  must  not  be  treated  less  favorably  than  persons 
of  other  nationalities.  Women  shall  be  admitted  on  the  same  terms 
as  men,  except  to  funds  of  a  trade  union  or  establishment  fund 


(») Report  of  the  Social  Insurance  Commission  of  California,  page  199,  Table  II. 

15 


224 

where  only  men  are  employed.  Insurance  benefits  shall  not  vary 
according  to  sex  unless  the  contributions  show  a  corresponding  varia- 
tion. No  person  shall  be  excluded  from  membership  for  religious 
or  political  causes.  Swiss  funds,  unlike  those  in  Denmark,  are  re- 
quired only  to  insure  to  their  members  either  medical  care  and  medi- 
cines or  a  daily  cash  benefit  of  not  less  than  one  franc  (19.3  cents),  be- 
ginning at  least  with  the  fourth  day  of  sickness.  Benefits  must  be 
paid  for  at  least  180  days  during  a  period  of  360  consecutive  days. 
Childbirth  must  be  regarded  as  an  illness  and,  provided  the  insured 
person  has  been  a  member  of  the  fund  for  nine  months,  both  cash  and 
medical  benefits  shall  be  provided  for  at  least  six  weeks,  and  if  the 
mother  nurses  the  child  an  additional  benefit  of  20  francs  (|3.86) 
must  be  paid. 

The  choice  of  physician  or  druggist  is  left  to  the  patient  unless 
the  fund  contracts  for  these  services.  Payment  for  medical  and 
pharmaceutical  aid  is  made  according  to  a  schedule  fixed  by  the 
cantonal  governments  in  conference  with  representatives  t>f  the 
funds  and  with  the  professional  associations  of  physicians  and  phar- 
macists. 

Recognized  societies  receive  the  following  annual  subsidies : 

1 — For  children  up  to  fourteen  years,  3.50  francs  (67.5  cents). 

2 — When  the  fund  insures  either  medical  care  or  cash  benefit, 

3.50  francs  (67.5  cents)  for  each  adult  male,  and  four  frans 

(77.2  cents)  for  each  adult  female. 

3 — If  the  fund  insures  both  medical  care  ami  cash  benefits, 

five  francs  (96.5  cents),  for  both  sexes. 
4 — If  the  fund  increases  the  benefit  period  from  180  to  360 

days,  an  additional  50  centimes  (9.7  cents). 
5 — For  each  confinement,  an  additional  20  francs  (|3.86). 
6 — For  each  nursing  benefit,  an  additional  20  francs  (P.86). 
7 — In  mountainous  districts  where  communication  is  difficult 
and  the  population  sparse,  an  additional  subsidy  of  seven 
francs  ($1.35). 
The  system  went  into  effect  on  January  1,  1914,  and  since  that 
time  10  cantons,  including  Zurich,  have  declared  the  insurance  com- 
pulsory. 

FRANCE. 
The  French  act  of  June  29,  1894  established  compulsory  sickness 
insurance  for  seamen  and  railway  employees,  and  for  miners  earn- 
ing up  to  2,500  francs  (|482.50)  per  year.  Under  this  system,  em- 
ployees contribute  not  more  than  tw^o  per  cent,  of  their  wages  or 
19.65  per  year,  employers  pay  a  sum  equal  to  one-half  of  the  contribu- 
tions from  employees,  and  subsidies  are  received  from  the  state  and 
from  charitably  inclined  persons.  Medical  attendance,  medicines  and 
cash  benefits  are  paid  to  sick  members,  and  death  benefits  and  an- 
nuities may  also  be  paid  to  dependents. 


225 

Since  1910  very  small  state  subsidies  have  been  paid  to  recognized 
voluntary  sick  benefit  societies  to  which  other  employees  might  be- 
long. Only  one-half  the  activity  of  these  societies  is  in  the  field  of 
sickness  insurance,  however,  as  funeral  benefits,  and  aid  to  widows, 
orphans,  invalids,  and  old  persons  are  also  included.  It  is  impos- 
sible to  tell  exactly  how  many  members  of  the  funds  are  insured 
against  sickness,  but  the  proportion  seems  to  be  very  low  and  the 
protection  afforded  far  from  adequate. 

COMPULSORY  HEALTH  INSURANCE. 

The  experience  of  these  various  countries  has  emphasized  several 
serious  faults  in  voluntary  health  insurance  systems.  The  most  ap- 
parent of  these  is  the  impossibility  of  reaching  the  most  needy  class 
without  compulsion.  In  all  voluntary  systems  the  proportion  of 
insured  is  in  inverse  ratio  to  the  economic  status.  The  willingness 
and  the  ability  to  insure  presuppose  a  degree  of  education  and  the 
existence  of  a  surplus  which  are  impossible  among  a  large  proportion 
of  employees  under  present  industrial  conditions.  Moreover,  little 
or  no  account  is  taken  in  voluntary  systems  of  the  responsibility  of 
industry  and  of  society  in  general  for  a  large  part  of  existing  sick- 
ness among  employees.  The  economic  burden  cannot  be  equitably 
divided  so  as  to  give  the  employer  and  the  state  their  full  share, 
but  is  left  to  be  borne  by  those  whose  resources  are  least  adequate  to 
meet  it.  Standardization  of  service  and  economy  of  administration 
are  almost  impossible  in  a  system  of  voluntary  insurance.  Standards 
are  invariably  lower  in  some  societies  than  in  others,  as  is  shown 
by  the  great  difference  in  the  character  and  amounts  of  medical  and 
cash  benefits  provided  and  by  the  varying  degrees  of  solvency  among 
the  funds. 

The  rapid  growth  of  compulsory  health  insurance  within  the  past 
decade  has  been  striking.  Since  1900,  nine  countries,  Luxemburg, 
Norway,  Serbia,  Great  Britain,  Kussia,  Roumania,  the  Netherlands, 
Sweden  and  Belgium  have  established  compulsory  systems. 

GERMANY. 
Germany  was  the  first  nation  to  adopt  the  principle  of  compulsory 
health  insurance.  The  sickness  insurance  law  of  1883,  passed  after 
years  of  experiment  with  varying  degrees  of  compulsory  insurance 
in  different  parts  of  the  Empire,  made  no  attempt  to  centralize  con- 
trol. Existing  agencies  were  utilized  to  the  fullest  possible  extent, 
the  aim  sought  being  mutual  insurance  with  self  administration. 
Insurance  was  made  compulsory  for  all  workingmen  and  technical 
employees  in  mines,  quarries,  factories,  and  other  industrial  concerns, 
and  eight  kinds  of  societies  were  recognized,  the  only  common  re- 


'  226 

quirement  being  that  they  should  make  annual  reports  and  conform 
to  provisions  regarding  minimum  benefits  and  methods  of  investing 
funds. 

1 — Commercial  societies  (Gemeindekrankenkassen)  were  estab- 
lished under  the  law  to  provide  insurance  for  all  persons  of  whatever 
occupation,  who  were  obliged  to  insure  but  did  not  belong  to  any 
other  sick  benefit  society. 

2 — Local  societies  (Ortskrankenkassen)  were  established  by  town- 
ships for  the  various  trades,  two  or  more  townships  often  uniting  to 
form  one  society.  At  present,  these  are  the  most  popular  of  all  the 
societies. 

3 — Factory  societies  (Betriebskrankenkassen),  created  by  propri- 
etors of  factories  in  which  more  than  50  workers  were  employed, 
particularly  in  trades  where  the  risk  of  sickness  or  accident  was 
high.  Management  was  under  the  joint  control  of  employees  and 
employers. 

4 — Builders'  societies  (Baukrankenkassen),  which  were  practically 
establishment  funds  founded  by  contractors  in  building  operations 
and  in  public  works,  because  of  the  great  risks  of  these  trades. 

5 — Guilds,  sick-clubs,  or  trade  societies  (Innungskrankenkassen), 
authorized  by  the  national  trades  regulation  law.  These  did  not 
possess  legal  personality,  but  were  considered  a  mere  function  of  the 
guilds  or  trade  unions. 

6 — Miners'  societies  (Knappschaftskassen),  formed  in  accordance 
with  the  mining  laws  of  the  several  kingdoms. 

7 — Voluntary  mutual  aid  societies  (Hilfskassen).  These  were  the 
friendly  societies  supported  and  controlled  solely  by  the  members 
without  any  participation  from  employers.  Membership  was  usually 
without  regard  to  trade.  They  were  not  under  the  control  of  authori- 
ties except  that  they  must  grant  the  minimum  benefits  required  by 
law. 

8 — Independent  state  societies  (Landesrechtlichehilfskassen).  These 
were  voluntary  associations,  organized  under  the  auspices  of  certain 
kingdoms  of  the  empire.^ 

In  1884  an  act  was  passed  providing  for  compulsory  accident  in- 
surance and  in  1889  old  age  and  invalidity  were  also  included  in 
the  insurance  system.  These  acts,  and  the  sickness  insurance  law 
with  numerous  amendments  and  additions,  were  embodied  in  the 
present  social  insurance  code  of  Germany,  in  1911.  This  act  added 
the  two  large  groups  of  domestic  and  farm  hands  to  those  already  j 
insured  as  well  as  various  minor  groups  of  professional  and  semi- ^ 
professional  employees.  The  first  13  weeks  of  accident  benefits  are 
also  taken  care  of  by  the  sickness  insurance  system. 

(1)  American  Medical  Association — Social  Insurance  Series,    Pamphlet  No.   11,   pages  14-16. 


227 

The  fundamental  features  of  the  sickness  insurance  law  may  be 
outlined  as  follows: 

I — Insured  Persons. 

a — All  workmen,  helpers,  journeymen,  apprentices,  persons  en- 
gaged in  home- working  industries,  and  servants  are  com- 
pelled without  regard  to  income  to  be  insured,  as  well  as 
all  other  persons  employed  and  earning  2,500  marks  (|595) 
a  year  or  less.  This  second  group  includes  about  250,000 
persons  in  commercial  and  professional  pursuits,  such  as 
druggists,  teachers,  and  members  of  theatrical  companies 
and  orchestras, 
b — Voluntary  members:  all  employees  whose  income  does  not 
not  exceed  2  500  marks  (|595)  and  who  are  not  under 
compulsion  to  insure;  members  of  an  employer's  family 
s  working  for  him  without  remuneration ;  tradesmen  who  do 
not  have  regular  employees,  or  at  the  most,  two.  In  these 
cases  the  fund  may  impose  an  age  limit* and  may  require 
applicants  to  submit  to  medical  examination. 

It  was  estimated  that  the  total  number  of  persons  who 
would  be  insured  under  the  law  from  July,  1912,  would  be 
12,918,000,  made  up  as  follows: 

•  Compulsory  contributors,  13,089,000  or  94  per  cent.; 
voluntary  contributors,  829,000  or  six  per  cent.  This  num- 
ber would  be  equal  to  about  31  per  cent,  of  the  total  pop- 
ulation, and  77  per  cent,  of  the  occupied  population,  of  the 
Empire.^  It  has  been  of  course,  because  of  the  war,  im- 
possible to  get  any  data  on  the  actual  number  of  those 
insured  since  the  law  went  into  effect. 
11 — Organization  and  Administration  of  Insurance. 

The  machinery  for  carrying  out  the  provisions  of  the 
health  insurance  law  is  entirely  of  a  mutual  character. 
The  funds  recognized  under  the  law  of  1883  are  still  used  as 
Insurance  carriers,  with  some  changes  made  by  the  1911 
insurance  code.  The  local  and  factory  societies  have  been 
recognized  as  the  standard  as  they  are  the  most  efficient 
types;  the  mutual  aid  societies  have  been  discouraged  by 
a  minimum  membership  requirement  of  1,000;  the  com- 
mercial societies  have  been  eliminated  and  in  their  stead  a 
new  type  of  so-called  rural  fund  has  been  established  to 
include  domestics,  farm  hands,  and  low-wage  workers.  It 
is  estimated  that  approximately  37  per  cent,  of  those  in- 
sured are  in  local  funds,  37  per  cent,  in  rural  funds  and  15 
per  cent,  in  establishment  funds,  leaving  only  about  10  per 
cent,  for  all  the  other  types  of  funds.^ 


(*) Social   Insurance   in  Germany,   W.    Harbutt  Davison,   page  31. 

(^)American  Medical  Association,    Social  Insurance  Pamphlet  No.    11,   page  15. 


228 

The  funds  are  practically  self-governing,  each  fund  hav- 
ing a  general  and  an  executive  committee.  Two-thirds  of 
the  members  of  the  general  committee  are  elected  by  the 
insured  employees  and  one-third  by  the  employers,  and  the 
members  of  the  executive  committee  are  chosen  in  the  same 
proportion  by  the  two  groups  of  the  general  committee. 

Supervision  is  exercised  through  a  state  administrative 
machinery  consisting  of  the  Imperial  Insurance  Office,  the 
Superior  Insurance  Offices,  for  districts  roughly  correspond- 
ing to  our  judicial  districts,  and  the  Local  Insurance  Offices 
for  districts  corresponding  to  our  counties  or  large  cities. 
In  each  of  these  offices  the  Government,  the  employers  and 
the  employees  are  represented. 

Ill — Contributions. 

These  are  managed  on  an  assessment  basis. 

a — If  the  employee  is  insured  through  a  mutual  aid  society, 
which  is  entirely  under  the  control  of  its  members,  no 
contribution  is  made  by  the  em»ployer.  This  is  also  true 
in  the  case  of  those  who  are  voluntarily  insured. 

b — Employees  insured  in  any  other  form  of  society  pay  two- 
thirds  the  cost,  and  the  employers  pay  one-third.  The 
actual  amounts  are  not  fixed  by  law,  but  vary  with  different 
funds  and  different  years.  However,  the  normal  maximum 
rate  is  four  and  one-half  per  cent,  of  the  basic  wage.  An 
increase  beyond  this  rate  requires  the  consent  of  both  em- 
ployers and  employees  as  represented  in  the  management 
of  the  fund,  unless  the  increase  is  necessary  to  provide  the 
regular  minimum  benefits.  In  the  latter  case,  such  consent 
is  necessary  to  raise  the  rate  above  six  per  cent.  In  1912 
the  usual  rate  of  contribution  was  from  two  to  three  per 
cent  of  the  wage  rate. 

c — Employers  are  held  responsible  for  the  collections  of  pay- 
ments from  their  employees,  and  are  permitted  to  deduct 
such  amounts  from  wages.  They  are  also  required  to  see 
that  their  employees  are  insured,  under  penalty  of  fine  and 
liability  for  the  cost  of  treatment. 

d — The  imperial,  state  and  communal  authorities  assume  a 
certain  part  of  the  cost  of  the  system,  by  paying  for  the 
supervision  and  giving  treatment  to  insured  persons  in 
public  hospitals  at  special  rates. 

The  following  table  shows  the  financial  details  of  the 
operation  of  the  German  Sickness  Insurance  System,  from 
1911  to  1913. 


229 

RESULTS  OF  THE  OPERATION  OF  GERMAN  INDUSTRIAL  SICK 
FUNDS,  1911  TO  1913,  (INCLUDING  THE  FIRST  13  WEEKS  OF  AC- 
CIDENT BENEFITS.i 


Total,  all  Funds. 
1911.                  1912.                  1913. 

Per  Member. 
1911.        1912.        1913. 

Number  of  funds,   _.. 

23,109 

13,619,048 

589.34 

5,772,388 
115,128,905' 

$98,125,165 
92,449, 30S 

93,420,889 
85,077,474 
19,933,505 

12,654,754 

36,552,748 

1,618,199 

2,029,064 

12,223,171 

66,036 

5,281,065 
74,096,997 

21,659 

13,217,705 

610.26 

5,633.956 
112,249,064 

$9&, 390,722 
93,679,394 

94,018,781 
85,617,576 
20,380,724 

13,020,038 
35,794,829 
1,715,038 
1,888,035 
12,745,733 
73,179 

5,140,414 
73,133,115 

21,342 

13.566,473 

635.67 

5,710,251 
117.436,644 

$104,909,309 
98,588,587 

103,000,076 
92,983,399 
22,358,051 

14,355.602 

38.446,843 

1.803,748 

1,911,602 

14,026,202 

81,352 

5,157,354 
73,986,569 

Average  meinbership, 





Average  membership  per  fund,— 

Cases  of  sickBess  of  members  in- 
volving disability,    __    

0.42 

8.45 

$7  20 
6  79 

6  86 
6  25 

1  46 

93 

2  68 
12 
15 
90 
005 

39 
5  47 

0.43 
8.49 

$7  52 
7  09 

7  11 
6  48 

1  54 

99 

2  71 
13 
14 
96 

005 

39 
5  53 

0.42 

Days  of  sickness  involving  pay- 
ment of  pecuniary  benefits  or 
hospital   treatment,    

Ordinary   receipts    (interest,    en- 
trance fees,  contributions,  sub- 
sidies,   and    miscellaneous    re- 
ceipts, exclusive  of  receipts  for 

8.66 

$7  73 
7  27 

7  59 

Contributions  and  entrance  fees. 
Ordinary    disbursements     (costs 
of  sickness,   refund  of  contri- 
bution and  entrance  fees,  cost 
of     administration,     exclusive 
of  those  for  invalidity  insur 
ance,    miscellaneous  disburse- 

Costs  of  sickness 

6  85 

Medical  treatment, 

1  65 

Medicines    and    other    cura- 
tives    _    

1.06 

Pecuniary  sick  benefits,  

283 
13 

Death  -(funeral)  benefits,  

Hospital  treatment 

14 
1.08 

Care  of  convalescents, 

Costs  of   administration   (exclu- 
sive   of    those    for    invalidity 

007 
45 

Excess  of  assets  over  liabilities. 

545 

IV— Benefits. 

a — The  law  specificalty  states  that  the  benefits  are  not  public 
charities.    The  right  to  benefits  begins  with  membership. 

b — Medical  benefits  include  medical,  hospital  and  nursing  care, 
medicines,  and  all  necessary  appliances,  trusses,  glasses, 
etc.,  from  the  beginning  of  illness  regardless  of  whether 
it  causes  inability  to  continue  working,  up  to  26  weeks  in 
one  year. 

c — Cash  benefits  equal  to  50  per  cent,  of  the  standard  wage, 
begin  with  the  fourth  day  of  illness,  and  are  paid  for  each 
working  day  lost  up  to  26  weeks  in  one  year.  The  insured 
are  classified  into  different  wage  groups,  but  the  basic  wage 
in  any  group  cannot  exceed  five  marks  (|1.19)  per  da3^ 
The  maximum  normal  sick  benefit  therefore  is  60  cents  per 
day.  When  the  patient  is  sent  to  a  hospital,  the  cash  bene- 
fit is  stopped  unless  needed  for  the  support  of  the  de- 
pendents. 

(i) Monthly  Report,   United  States  Bureau  of  Labor  Statistics,   April,   1916,  ^age  98. 


230 

d — Maternity  benefits  equal  to  the  cash  benefits  described 
above  are  provided  for  insured  women  for  a  period  of 
eight  weeks,  of  which  six  must  be  after  delivery.  Instead 
of  this  benefit,  home  treatment  or  hospital  care  with  half 
cash  benefit  nVay  be  given.  The  same  cash  benefits  are 
provided  for  six  weeks  for  disability  due  to  pregnancy, 
e — Funeral  benefit  in  case  of  death  of  the  insured  equals 
twenty  times  the  basic  daily  wage. 

"But  while  these  four  forms  of  benefits  constitute  the 
legal  minimum  required  by  the  sickness  insurance  funds, 
they  give  a  very  inadequate  conception  of  the  entire  serv- 
ice rendered.  In  various  ways  the  insurance  may  and  does 
extend  the  minimum  amounts,  and  within  the  prescribed 
limits  of  the  acts  establishes  even  other  benefits  dealing 
with  sickness. 

"These  so-called  optional  benefits  may  be  classified  as 
follows : 

1 — Increase  of  compulsory  benefits. 

(a) — Increase  of  sick  benefit  up  to  75  per  cent,  of 

wages. 
(b) — Grant  for  Sundays  and  holidays. 
(c) — Extension   of     sick    benefits   up   to    fifty-two 

weeks. 
(d) — Keduction  or  abolition  of  the  waiting  period 
in  all  cases,  or  only  in  cases  of  industrial  ac- 
cidents, or  in  cases  lasting  over  one  week. 
(e) — Increase  of  benefit  payable  to  family  when  in- 
sured receives  hospital  treatment,  from  one- 
half  tu  the  full  amount  of  the  sick  benefit, 
(f) — Increase  of  funeral  benefit,  up  to  forty  times 

the  daily  wage. 
(g) — Increase  of  minimum  for  funeral  benefits  to 
50  marks  (|11.90). 
2 — New  Benefits. 

(a) — Hospital  treatment. 
(b) — Nurses'  attendance. 

(c) — Appliances  to  prevent    disfigurement    or    de- 
formity, 
(d) — Grant  of  special  diets.  ^ 

(e) — Grant  of  other  therapeutic  means. 
(f ) — Sick  benefits  (up  to  one-half  the  regular  sick 
benefit)  to  insured  persons  under  treatment  in 
hospitals, 
(g) — Pregnancy  benefits  up  to  six  weeks, 
(h) — Medical  treatment  for  ailments  due  to  preg- 
nancy. 


231 

(i) — Nursing  benefits  (or  motherhood  benefits)  up 
to  twelve  weeks  after  confinement. 

(j) — Convalescent  care  up  to  one  year  after  illness. 
3 — Extension  of  Benefits  to  Dependents. 

(a) — Medical  treatment^  to  dependent  family. 

(b) — Maternity  benefit  to  wife  of  insured. 

(c) — Funeral  benefits  for  death  of  husband  or  wife 
or  child. 
"Many  of  the  funds,  and  especially  the  larger  ones  in  the 
large  cities,  have  embodied  some  of  those  permitted  exten- 
sions, of  which  the  most  important  are  the  increase  of  the 
money  benefit  above  the  legal  minimum  of  50  per  cent,  of 
wages,  the  extension  of  both  the  medical  and  money  benefits 
beyond  the  minimum  of  26  weeks,  the  establishment  of  a 
compulsory  hospital  benefit,  which  is  not  specifically  re- 
quired by  the  law,  increase  of  the  duration  of  the  maternity 
benefits,  convalescent  care  and  extension  of  the  medical, 
maternity  and  funeral  benefits  to  the  immediate  family  of 
the  insured.^  This  very  wide  utilization  of  the  possibilities 
of  democratic  management  of  the  fund  is  a  very  significant 
feature  of  the  development  of  health  insurance  in  Germany. 
Concerning  one  or  two  of  these  features  accurate  informa- 
tion is  available. 

"The  great  majority  of  the  funds  have  not  exceeded  the 
minimum  requirements  regarding  the  number  of  weeks  for 
which  cash  benefits  are  paid,  but  the  increase  of  the  weekly 
benefit  over  the  minimum  amount  is  much  more  frequent. 
Detailed  information  concerning  some  of  the  extensions  by 
large  funds  is  given  in  I.  G.  Gibbon's  "Study  of  Medical 
Benefits  in  Germany  and  Denmark,"  page  278,  for  twenty- 
eight  large  local  funds,  with  a  combined  membership  of 
1,100,000.  Eighteen  of  these  funds  paid  sick  benefits  of  50 
per  cent.,  one,  55  per  cent.,  one,  58.5  per  cent.,  six,  60  per 
cent.,  and  one,  62.5  per  cent,  of  wages.  In  two  funds  the 
waiting  period  was  reduced  to  two  days  and  in  five  funds 
to  one  day.  One  fund  extended  the  period  of  money  benefits 
to  thirty-four  weeks,  two  to  thirty-nine  weeks  and  three  to 
fifty-two  weeks.  Ten  funds  provided  convalescent  homes, 
and  eight  had  day  convalescent  resorts.  Twenty-one  out 
of  these  twenty -eight  funds  granted  medical  aid  to  the  mem- 
bers of  the  family,  and  twelve  gave  drugs  as  well.  Seven- 
teen funds  have  provided  funeral  benefits  in  case  of  death 
of  the  wife,  and  of  these,  fifteen  also  paid  the  funeral 
expenses  in  case  of  death  of  children."^ 

(^) Report  of  the   Social   Insurance  Commission   of  the  State  of  California,   page   157. 


232 

V — Organization  of  Medical  Aid.^ 

Medical  as  well  as  cash  benefits  are  administered  by  the 
funds  themselves,  and  each  fund  has  an  absolutely  free 
hand  in  the  method  of  remunerating  the  physicians. 
Throughout  Germany  there  exist  official  scales  of  medical, 
surgical  and  dental  fees,  and  in  the  absence  of  formal 
agreements  between  the  physicians  and  the  funds  it  follows 
that  payment  will  be  made  by  attendance  according  to  the 
minimum  fees  of  the  official  scale. 

The  federation  of  sickness  funds  in  Bremen  is  the  only 
large  organization  known  to  pay  its  medical  staff  uncondi- 
tionally on  this  principle,  however,  the  usual  plan  being 
for  the  fund  to  contract  with  a  number  of  physicians  who 
give  their  services  in  return  for  a  fixed  annual  salary,  as 
in  Dresden,  or  for  compensation  according  to  a  capitation 
system.  Under  such  a  system,  the  physician  may  receive 
a  fixed  fee  per  capita  per  year  for  all  insured  persons  whom 
he  undertakes  to  attend,  with  or  without  certain  special 
services  according  to  the  terms  of  the  agreement;  he  may 
be  paid  a  fixed  rate  per  case  of  sickness  attended,  although 
this  is  an  uncommon  practice ;  on  there  may  be  a  capitation 
fund  of  a  stated  amount,  divided  according  to  services 
rendered  each  patient,  each  service  counting  so  many 
points.  This  last  is  the  method  most  commonly  used.  In 
no  instance  is  a  charge  based  only  on  the  number  of  visits 
or  prescriptions.  Physicians  are  not  required  to  furnish 
medicines,  but  send  the  prescriptions  to  be  filled  by  the 
pharmacist  of  the  patient's  choice. 

As  a  rule,  the  insured  person  has  free  choice  between  at 
least  two  physicians,  and  may  be  permitted  to  change  from 
one  physician  to  another  for  certain  sensible  reasons.  In 
Leipzig,  80  per  cent,  of  the  physicians  are  on  the  panel  of 
the  Jjcipzig  Fund  and  consequently  a  wide  choice  is  pos- 
sible. 

Between  1896  and  1911  there  was  a  marked  increase  in 
the  cost  of  medical  treatment,  due  not  only  to  the  higher 
fees  paid  to  physicians,  but  to  the  broader  scope  of  treat- 
ment due  to  the  progress  of  therapeutics,  to  the  extension 
of  treatment  by  specialists,  and  to  the  increased  recogni- 
tion by  the  working  classes  of  the  importance  of  health  and 
their  willingness  to  make  sacrifices  to  obtain  it. 

The  funds  are  usually  disposed  to  give  a  very  liberal 
interpretation  to  medical  treatment.  The  treatment  by 
specialists  under  most  funds  depends  on  the  recommenda- 
tion by  the  general  practitioner  first  consulted,  but  in  some 

(^)American  Medical  Association — Social   Insurance  Pamphlet  No.    11,   pages   24-40. 


283 

towns,  such  as  Munich,  members  are  allowed  to  go  directly 
to  any  specialist  on  the  medical  list  without  previous  rec- 
ommendation. Specialists  with  whom  the  large  sickness 
funds  conclude  agreement  are  those  for  eye,  ear,  nerve,  skin, 
throat,  stomach  and  women's  diseases.  Medical  treatment 
often  comprises  Roentgen-ray  applications,  electric  treat- 
ment and  mechanical  exercises.  In  1912  the  central  com- 
mittee of  the  sickness  funds  in  Berlin  completed  the 
equipment  of  an  establishment  for  general  use,  including 
Roentgen-ray,  hydrotherapeutic,  electric  and  physical  treat- 
ment on  a  large  scale,  and  in  the  course  of  the  first  fifteen 
months,  6,800  persons  were  treated.  Some  of  the  large 
federations  of  sickness  funds,  like  those  of  Leipzig  and 
Dresden,  have  well  equipped  rooms  attached  to  their  cen- 
tral oflSces  in  which  mechanical  treatment  is  given  in  the 
most  approved  methods.  The  large  sickness  funds  in  the 
towns  also  provide  their  sick  members  with  medical  baths 
of  great  variety. 

Among  all  classes  in  Germany  there  seemis  to  be  general 
satisfaction  with  the  health  insurance  law.  Standards  of 
living  among  working  men  and  women  have  been  raised 
"  by  its  operation  and  loss  of  working  time  greatly  decreased 
by  prompt  attention  to  incipient  illness.  The  testimony 
of  employers,  employees,  and  public  officials  is,  so  far  as 
is  known,  unanimously  in  favor  of  the  system. 

GREAT  BRITAIN.  -~ 

The  National  Insurance  Act  of  Great  Britain,  providing  for  both 
compulsory  health  and  old  age  insurance,  pas  passed  on  December  16, 
1911,  and  became  operative  July  15, 1912.  Unlike  the  German  system, 
which  grew  slowly  as  the  result  of  experiments  with  state  subsidies 
and  control  of  sick-benefit  societies,  the  British  system  was  all-in- 
clusive from  the  beginning. 

Before  the  passage  of  the  law  the  bulk  of  health  insurance  was 
handled  by  the  powerful  lodges  and  friendly  societies  and  the  trade 
unions.  More  than  5,500,000  of  the  more  thrifty  British .  workmen 
were  voluntarily  insured  in  this  way,  leaving  about  8,000,000  workers 
unprotected.  The  influence  of  the  fraternals  was  strongly  felt  in  the 
formulation  of  the  act,  under  which  they  remain  the  chief  carriers 
of  insurance.  The  continuation  of  these  national  societies  is  one  of 
many  striking  differences  from  the  German  system,  which  has  forced 
the  localization  of  all  approved  societies.  In  fact,  except  for  the 
underlying  principle  of  compulsion,  the  two  systems  have  so  little  in 
common  that  they  may  well  be  taken  as  different  types  of  state  health 
insurance. 


234 

I — Insured  Persons: 

a — All  persons  between  the  ages  of   sixteen    and    sixty-five 
years^  who  are  employed  at  manual  labor,  without  regard 
to  income,  and  other  employed  persons  earning  less  than 
\60  pounds   (1778.64)  a  year,  are  compelled  to  insure.     A 
person  insured  when  under  sixty-five  remains  insured  if 
employed  until  he  is  seventy.    Exceptions  are  made  in  the 
case  of  persons  in  the  naval  or  military  service,  those  em- 
"  ployed  by  public  authority,  railwa}^  employees,  teachers, 
and  other  persons  for  whom  provision  has  already  been 
made,  and  for  a  few  casual  and  part-time  employees, 
b — Voluntar}^  miembers  include  all  persons  who  are  employed 
and  are  dependent  on  their  earnings  for  their  livelihood, 
and    whose    total    income    does    not    exceed    160    pounds 
(1778.64)  a  year.    In  addition  those  who  have  been  insured 
persons  for  five  years  or  longer  may    become    voluntary 
members  regardless  of  earnings, 
c — No  person  who  is  sixty-five  years  of  age  or  older  may  be- 
come insured  under  the  act,  and  no  person  may  continue 
to  be  insured  after  he  reaches  the  age  of  seventy,  when 
he  is  taken  care  of  by  the  old  age  pensions  system. 
II — Organization  and  Administration  of  Insurance 
Unlike  European  systems  of  health  Insurance,  the  Britisk-S^i^m 
encourages  the^conjljaiifttion  of  benefit  societies  by  allowing  them  to 
Uppoiup  thp  TnaiTi  carriers  of  insurance.  _Paxticipation  is  open_to_AU-^ 
sick-benefit  societies,  trade  unions,  establishment  funds  and  similar 
organizations  which  can  cojiform  to  the  tieguirements  fox-llajumoved 
societies,"   the  most  ^'mp^^ta^t  ^^  whic^    ^^^  .thflt-^they  must  not 


operate  fox-profit  and  must  be  controlled  by  their  mfjnbers.  In  spite 
oTthislast  provision  many  "approved  societies"  have  been  organized 
by  industrial  life  insurance  companies  and  are  under  very  little  demo- 
cratic control.  It  is  impossible  to  ascertain  the  number  of  persons 
insured  in  various  types  of  societies  since  1914,  but  the  following 
table  shows  the  situation  just  prior  to  the  outbreak  of  the  war. 

MEMBERS     OF    APPROVED     SOCIETIES.     GREAT    BRITAIN,     IMMED- 
IATELY   PRECEEDING    THE    OUTBREAK   OF   THE   WAR. 


Friendly  Societies  with  branches, 

Centralized  Friendly  Societies,   

Industrial  and  Collecting  Societies 

Trade  Unions,    

Employers  Provident  Funds, 

Totals,    


Men. 


2,517,363 
2,649,450 
3,136,766 
1,267,064 
95.917 


9,666,560 


Women. 


711,230 
1,021,601 
2,168,066 

225,149 


4,156,298 


Total. 


3,671,051 

5,304,832 

1,492,213 

126.169 


13.822,858 


235 

Technically,  the  insured  person  has  unrestricted  choice  of  his  so- 
ciety. This  is  unlike  the  German  system  wheie  he  must  belong  to 
the  society  of  his  trade  or  locality.  Bjlit  the  societies  in  Great  Britain 
also  have  the  right  to  refuse  an  applicant  for  membership,  althougJi 
not  because  of  age  alone.  Persons  who  thus  fail  to  gain  admissieo^ 
to  any  society  become  "deposit  contributors"  by  depositing  their  con- 
tributions with  the  post  ofl&ce.  They  may  draw  benefits  only  up  to 
the  amount  of  their  individual  balances  and  so  are  not  injured  in  any 
real  sense.  The  failure  to  provide  special  institutions  for  the  insur- 
ance of  such  persons  is  generally  considered  a  defect  in  the  British 
system.  The  provision  for  "deposit  contributors''  was  intended  to 
be  only  a  temporary  one,  but  has  been  continued  because  of  the  war. 
However,  there  were  only  about  352,000  persons  provided  for  in  this 
way  just  before  the  war,  as  against  13,827,828  in  the  approved  so- 
cieties.^ 

The  administration  of  cash  benefits  for  members  of  approved  so- 
cieties is  left  entirely  to  the  societies,  but  the  medical  benefits  are 
administered  by  238  local  insurance  committees,  one  for  each  county 
or  borough.  This  separation  of  the  administration  of  the  cash  and 
medical  benefits  was  made  necessary  because  the  supplying  of  medical 
care  was  distinctly  a  local  problem  and  could  not  be  handled  by  the 
societies;  which  do  not  operate  within  geographic  limits.  The  Insur- 
ance Committees,  which  were  instituted  to  secure  some  uniformity 
in  the  medical  benefits  provided,  consist  of  from  forty  to  eighty  mem- 
bers, of  whom  three-fifths  represent  the  insured  persons,  one-fifth  (of 
whom  two  at  least  must  be  women)  are  appointed  by  the  county  or 
iJbrough  council,  two  members  are  elected  by  the  medical  practi- 
tioners in  the  district,  and  the  remaining  members  by  the  insurance 
commissioners.  Of  the  insurance  commissioners  at  least  one  must 
be  a  medical  practitioner  and  at  least  two  must  be  women.  These 
committees  administer  the  medical  benefits  for  members  of  approved 
societies,  both  the  cash  and  the  medical  benefits  for  "deposit  con- 
tributors," keep  records,  and  promote  measures  for  the  prevention  of 
disease.  They  may  inquire  into  the  causes  of  excessive  sickness  in 
any  locality  and  may  prosecute  any  persons  responsible.  To  defray 
the  expenses  of  these  committees,  each  society  having  members  who 
are  insured  persons,  resident  in  the  county  or  county  borough,  pays 
two  cents  annually  for  each  such  member. 

Both  the  approved  societies  and  the  insurance  committees  are  under 
the  control  of  four  National  Insurance  Commissions,  oi^e  for  each  ef 
the  four  parts  of  the  United  Kingdom.  These  Commissions  are  ap- 
opinted  by  the  Treasury  Department,  and  must  contain  at  least  one 
medical  practitioner.  They  may  make  rules  to  govern  all  insurance 
administration.  To  insure  uniformity,  a  joint  committee  for  the 
United  Kingdom  exists,  representing  the  four  Insurance  Commissions. 


(1)  Report  of  the  administration  of  the  National  Health  Insurance,  1914-17. 


236 

An  advisory  committee  has  been  appointed  by  each  Insurance 
Commission,  composed  of  representatives  of  employers'  associations, 
"approved  societies"  of  employees,  the  medical  profession  and  others, 
at  least  two  of  whom  must  be  women. 

1 1 1 — Contributions. 

The  cost  of  the  system  is  born  by  payments  from  the  employer, 
the  employee,  and  the  state.  Unlike  the  continental  laws,  which 
provide  for  contributions  on  an  assessment  basis,  the  British  law 
fixes  the  rate  of  premium  as  well  as  the  rate  of  benefits.  The  stand- 
ard cost  of  insurance  is  fixed  at  nine  pence  per  week  for  each  male 
insured  and  eight  pence  for  each  female,  irrespective  of  age  or  occu- 
pations. This  cost  is  divided  between  the  three  contributors,  the 
ratio  of  payment  being  determined  by  the  wages  and  sex  of  the  em- 
ployee. 

A — If  the  employee  earns  2  s.  6  d.  (61  cents)  or  more  per  day, 
the  payments  are  fixed  as  follows: 

Employer,  3  d.   (6  cents)  a  week 

C  Male,   4  d.   (8  cents)   a  week 

Employee   jpemale,   3d.   (6  cents)   a  week 

Government,   2  d.   (4  cents)   a  week 

B — If  the  employee  earns  between  2  s.  (49  cents)  and  2  s.  6  d. 
(61  cents)  per  day: 

(for  male  employee,  . . .  ,4  d.  (8  cents)  a  week 
Employer  j^^^.  f^j^^le  employee,  ..3d.  (6  cents)  a  week 

Employee, 3d.  (6  cents)  a  week 

Government, 2d.  (4  cents)  a  week 

C — If  the  employee  earns  between  1  s.  6  d.  (37  cents)  and  2  s_. 
(49  cents)  per  day: 

Cfor  male  employee,  . .  .5  d.  (10  cents)  a  week 
Employer  |^^^  female  employee,  .  .4  d.  (  8  cents)  a  week 

Employee, Id.  (  2  cents)  a  week 

Government,    3d.  (  6  cents)  a  week 

D — If  the  employee  earns  less  than  1  s.  6  d.  (37  cents)  per  day: 
(for  male  employee,  .  .6  d.   fl2  cents)   a  week 
Employer  |  for  female  employee,  .5  d.   (10  cents)   a  week 

Government 3  d.   (6  cents)   a  week 

In  no  case  can  the  employer  be  made  to  pay  more  than  6  d.  (12 
cents)  per  cent,  per  employee,  or  the  employee  more  than  4  d.  (8 
cents)  per  week. 

The  cost  of  administration  is  borne  by  the  entire  fund. 
Collections  are  made  by  the  sale  of  stamps  through  the  post  office, 
the  proceeds  of  which  go  to  the  Insurance  Commission.  The  em- 
ployer pays  both  his  own  share  and  that  of  his  employees,  and  is 
authorized  to  deduct  from  wages  the  payments  made  for  employees. 
The  stamps  are  placed  on  cards  which  are  collected  quarterly  by 
the  societies,  under  regulations  made  by  the  Insurance  Commis- 
sioners.    The  societies  in  turn  collect  from  the  Commissioners  pro- 


237 

rata  amounts  for  the  purpose  of  paying  benefits  and  covering  the 
cost  of  administration.  The  Insurance  Committees  also  receive  from 
the  Commissioners  money  to  cover  the  cost  of  medical  aid  and  ad- 
ministration. 

This  flat  rate  contribution  which  is  so  different  from  the  assess- 
ment system  used  in  Germany,  is  based  on  the  cost  of  supplying  all 
the  benefits  to  a  person  from  sixteen  to  seventy  years  of  age,  and 
medical  and  sanatorium  benefit  throughout  life.  The  greater  sick-, 
ness  rate  oflater  lite  has  been  allowed  for  by  fixing  the  flat  rate  top 
high  fortji^^w-^ga^oups  and  too  low  for  the  high-age^sXQB^-  By 
this  method  a  reserve  is  created  to  meet  the  increasing  claims  of  later 
life.  A  uniform  contribution  for  the  various  ages  insured  at  the 
inauguration  of  the  system  was  made  possible  by  crediting  to  the 
societies,  for  members  over  sixteen  years  of  age,  the  am;ounts  which 
would  have  accumulated  to  the  credit  of  these  members  if  they  had 
been  insured  from  the  age  of  sixteen.  These  "reserve  values"  made 
an  aggregate  total  of  |432,000,000,  which  appeared  at  first  only  as 
a  book  credit.  About  one-fifth  of  each  week's  contribution  is  de- 
voted to  converting  this  into  cash  and  providing  interest  on  the 
capital  sum,  a  process  which  it  was  originally  estimated  would  take 
from  eighteen  to  twenty  years.  When  the  total  amount  has  been 
written  off,  the  released  one-fifth  of  the  contributions  may  be  used 
for  increasing  benefits. 

Serious  criticism  has  been  made  of  this  flat  rate  of  contribution. 
Several  errors  were  made  in  the  calculation  of  the  British  sickness 
rate,  especially  for  women,  and  it  has  been  found  very  difficult  to 
change  the  premium  rate,  which  the  contributors  regard  as  fixed. 
It  has  been  found  equally  hard  to  change  the  rate,  even  to  provide 
more  adequate  benefits,  and  necessary  additional  expenditures  have 
had  to  be  met  by  the  government.  The  flat  rate  is  especially  un- 
satisfactory when  coupled  with  unrestricted  freedom  in  the  choice 
of  carriers,  because  of  the  possible  segregation  in  separate  societies 
of  persons  by  trade  or  sex,  frequently  resulting  in  an  isolation  of 
risk  far  below  or  above  the  average  hazard  for  the  entire  insured 
population  for  which  the  flat  contribution  was  calculated.  Since 
the  societies  are  financially  independent  of  each  other,  and  one  is 
unable  to  benefit  from  the  surplus  of  another,  it  has  been  necessary 
to  set  aside  a  portion  of  the  reserve  fund  as  a  "special  risk  fund'' 
from  which  unfortunate  societies  may  recoup  themselves.^ 

IV— Benefits. 

Instead  of  establishing  a  schedule  of  minimum  benefits  which 
approved  societies  must  provide  and  may  exceed,  the  British  act 
established  a  uniform  system  of  services  which  are  rarely  extended. 

(»)01ga  S.   Halser.    "Compulsory  Health  Insurance  in  Great  Britain." 


238 

a — Medical  benefits  begin  with  the  first  day  of  illness  and 
include  medical  attendance  and  treatment,  medicines,  and 
such  appliances  as  may  be  prescribed  under  regulations 
made  by  the  Insurance  Commissioners.  These  benefits  are 
much  less  carefully  defined  than  in  the  German  system,  and 
actually  guarantee  only  treatment  by  an  ordinary  prac- 
titioner. They  do  not  specifically  include  obstetrical  aid, 
operations,  hospital  care  or  nursing,  although  several 
Parliamentary  grants  have  been  made  to  provide  these 
services  to  a  limited  extent.  Medical  and  dental  care  for 
dependents  is  optional  with  the  societies. 

b — Sanatorium  benefit  for  persons  suffering  with  tuberculosis 
is  provided  through  the  insurance  committees  which  make 
arrangements  with  the  local  authorities. 

c — The  cash  benefit  is  not  based  upon  wages,  as  in  Germany, 
but  is  affixed  uniformly  at  ten  shillings  (|2.40)  a  week 
for  men  and  seven  shillings  six-pence  (|1.80)  for  women, 
for  a  period  of  twenty-six  weeks  in  each  year,  beginning 
with  the  fourth  day  of  incapacity.  A  disablement  benefit 
of  five  shillings  (|1.20)  a  week  is  paid  to  both  men  and 
women  who  have  been  insured  for  two  years,  w^hen  the 
illness  extends  beyond  twenty-six  weeks.  This  payment 
may  continue  for  the  entire  duration  of  the  incapacity,  or 
until  the  insured  reaches  the  age  of  seventy.  To  be 
eligible  for  cash  benefit,  the  insured  person  must  have 
been  insured  for  at  least  twenty-six  weeks  and  at  least 
twenty-six  weekly  contributions  must  have  been  paid  by  or 
for  him.  Provisions  are  made  for  paying  reduced  rates 
of  sick  benefit  to  unmarried  persons  under  twenty-one 
years  of  age  having  no  dependents ;  to  persons  fifty  years 
of  age  and  over  who  become  insured  within  one  year  from 
the  commencement  of  the  act  and  who  at  the  time  they 
claim  benefits  have  paid  less  than  five  hundred  weekly 
contributions;  to  certain  persons  of  the  age  of  seventeen 
or  more  who  become  insured  later  than  one  year  from  the 
commencement  of  the  act,  and  to  persons  whose  dues  are 
in  arrears. 

d — Maternity  Benefits — In  the  case  of  an  employed  woman  or 
the  wife  of  an  insured  man,  a  lump  sum  of  30  shillings 
(17.30)  is  paid  for  confinement.  This  payments  is  made 
solely  to  help  pay  the  expenses  incident  to  confinement,  as 
no  medical  care  is  provided.  If  the  mother  is  ,an  insured 
person  and  married,  she  is  entitled  to  sickness  or  disable- 
ment benefit  in  addition  to  the  maternity  benefit,  but 
except  for  such  cases,  no  woman  is  entitled  to  sickness  or 


239 

disablement   benefit   during  two   weeks^  before   and   four 
weeks  after  confinement,  except  for  a  disease  or  disable- 
ment not  connected  with  childbirth, 
o  funeral  benefit  is  granted  under  the  Act. 


V — Organization  of  Medical  Aid. 

The  Insurance  Committees,  under  the  supervision  of  the  Commis- 
sioners, arrange  for  medical  care  of  insured  persons  and  draw  up- 
^^panels"  or  lists  of  physicians.  In  making  these  arrangements,  two 
fundamental  conditions  must  be  recognized:  the  right  of  every  duly 
qualified  physician  who  wishes  to  serve  upon  a  panel  to  a  place  upon 
it,  provided  he  has  not  been  show^n  to  be  injurious  to  the  service,  and 
the  right  of  every  insured  person  to  choose  his  physician  from  those 
on  the  panel.  A  minimum  of  |1.68  and  a  maximum  of  |1.80  per  jjer- 
son,  is  annually  set  aside  for  the  remuneration  of  physicians,  regard- 
less of  the  amount  of  treatment  given  in  individual  cases. 

ATTITUDE  OF  ME-DICAL  PROFESSION. 

^^ About  ten  years  ago  it  became  evident  in  England  that  the  cir- 
cumstances under  which  the  general  practice  of  medicine  could  take 
place  were  rapidly  becoming  less  and  less  advantageous  to  the  pro- 
fession."^ The  reduction  of  infectious  diseases  through  preventive 
medicine  and  public  hygiene  and  the  substitution  of  midwives  for 
physicians  at  conffhement  had  done  much  to"  reduce  the  incomes  of 
practitioners  among  the  poor.  It  was  well  recognized  that  such  prac- 
ticB  meant  very  small  fees  with  many  bad  debts,  and  that  the  poor 
could  not  pay  for  their  medical  care  without  suffering  serious 
financial  embarrassment.  Numerous  clubs,  and  medical  associations* 
had  sprung  up,  and  lodge  practice  and  club  practice  had  become  so* 
prevalent  that  in  1905  the  British  Medical  Association  made  an  in- 
vestigation of  the  situation.  Their  report  showed  that  the  usual- 
method  of  payment  was  by  capitation,  resulting  often  in  inadequate 
payment  for  excessive  work,  and  poor  medical  return  to  the  patient. 
The  average  fee  obtained  per  visit  Avas  about  21  cents,  and  each  clubr 
member  was  attended  on  an  average  four  times  per  year.^ 

Various  plans  for  the  establishment  of  medical  associations  to  conk- 
pete  with  the  lodges  were  under  consideration  when  the  Nati©»al^ 
Insurance  Act  was  proposed.  The  British  Medical  Association  pre- 
sented six  cardinal  j)oints  which  it  desired  to  have  incorporated  into> 
the  act.  Four  of  these,  providing  for  free  choice  of  physician  by  the 
patient  subject  to  the  consent  of  the  physician  to  act ;  medical  benefit 
to  be  administered  by  the  insurance  committees  and  not  by  the 
societies ;  adequate  medical  representation  among  the  Insurance  Coi»- 
missioners  and   on   the  local   insurance   committees,   and   statutory 

CJAmMipaH    Medical    Association — Social    Insurance   Paisphlet   No.    11,    pages   46-7. 

16 


240 

recognitixMi  of  a  local  medical  committee  representative  of  the  pro- 
fession in  the  district  of  each  insurance  committee;  and  an  equitable 
adjustment  of  differences  regarding  amount  and  method  of  remunera- 
tion of  physicians  were  adopted  and  made  a  part  of  the  Act.  There 
were  Mumerous  controversies  between  the  Medical  Association  and 
the  government  regarding  the  rate  of  capitation  payment,  but  the 
majority  of  the  profession  at  once  accepted  service  under  the  Act. 
■At  present  from  70  to  100  per  cent,  of  the  physicians  in  the  various 
-districts  are  on  the  insurance  panels. 

''On  January  17th,  1917,  the  Insurance  Acts  Committee  of  the 
lk*itish  Medical  Association  decided  to  ask  each  Branch  and  Division 
\^f  the  Association  and  each  Local  Medical  and  Panel  Committee.,  or 
such  bodies  acting  in  co-operation,  to  appoint  a  thoroughly  represen- 
tative Subcommittee  .to  consider  the  present  system  of  National 
Health  Insurance,  so  far  as  it  affects  the  relation  of  the  medical  pro- 
fession to  the  public  health  and  the  treatment  of  disease,  and  to  make 
miggestions  for  its  improvement.  The  hope  was  expressed  that  all 
possible  steps  would  be  taken  to  ascertain  the  opinions  of  as  many 
men  as  possible  on  military  servlbe  and  certain  questions  were  asked 
in  order  Miat  attention  might  be  directed  to  certain  specifie  points. 
"  ^'Tlie  degree  of  unanimity  so  far  disclosed  is  somewhat  remarkable. 
Cki  a  subject  which  five  years  ago  was  the  mest  highly  controversial 
that  had  ever  been  before  the  profession,  and  which  still  in  some 
places  and  everywhere  in  some  of  its  aspects,  excites  argument,  it  is 
found  (1^  that  many  matters  which  at  the  beginning  of  the  contro- 
^yersj  gave  rise  to  most  apprehension  have  assumed  a  position  of 
^•quite  minor  importance;  (2)  that  the  general  system  by  which  the 
Btate  provides  medical  advice  and  treatment  under  the  insurance 
sciieme  is  in  the  main  approved,  and  that  criticisms  have  a  tendency 
to  concentrate  on  a  comparatively  few  points  which,  though  of  great 
importance  and  indeed  vital  to  smooth  working,  are,  after  all,  matters 
lof  detail  which  ought  to  be  capable  of  adjustment;  (3)  that  there  is 
a  large  body  of  opinion  in  favor  of  the  extension  of  the  health  insur- 
Jince  system  both  to  kinds  of  treatment  not  at  present  provided  for 
•and  to  'Classes  of  persons  at  present  excluded  therefrom."^ 

The  report  of  tke  Committee  goes  on  to  state  that  the  medical  pro- 
tfession^  insured  persons  and  government  officials  seem  to  be  in  accord 
^it^  fke  principle  of  the  Act,  and  that  i  all  elements  unite  in  demand- 
ing more  adeqnate  medical  and  surgical  aid,  .as  well  as  numerous 
clian:ges  in  the  details  of  operation  of  the  system.  A  long  list  of 
suggestions  for  improvements  have  been  formulated  by  the  Insurance 
Acts  Obmmittee  of  the  British  Medical  Association  to  be  presented 
a^  possible  amendments  to  the  Act. 

('^British  Medical.  Association,  Insurance  Acta  Committee,  Interim  Report  on  the  Future  of 
the  Insurance  Actsij  1917. 


241 
OTHER  COMPULSORY    SYSTEMS. 

The  health  insurance  systems  of  Austria  (1888),  Hungary  (1891), 
Luxemburg  (1001),  and  Koumania  (1012)  are  organized  in  the  same 
way  as  the  German  system  and  differ  from  it  only  in  a  few  minor 
details.     The  most  important  difference  is  the  experiment  introduced 
in  Hungary  in  1007,  when  all  the  local  funds  were  consolidated  into 
two  national  insurance  societies.     The  Serbian  law  (1010)  includes 
only' employees  of  establishments  subject  to  the  industrial  act  which, 
covers  mining,  transportation,  trade,  and  certain  other  industries. 
The  Russian  Act  (1012)  is  also  limited  in  its  scope,  covering  factories,, 
mines,  metallurgical  establishments,  inland  navigation,  street  rail- 
ways and  some  local  steam  railroads,  provided  that  they  employ  at 
least  twenty  hands,  and  use  some  form  of  mechanical  power,  or  that 
if  they  do  not  use  mechanical  power  they  employ  at  least  thirty 
hands.     Only  about  20  per  cent,  of  the  wage  workers  are  thus  pro- 
vided for.     Cash  benefits  resemble  those  furnished  by  the  German 
system,  but  no  medical  care  is  provided,  because  by  a  law  of  1866, 
employers  in  factories  and  mines  are  required  to  provide  free  medical 
care  for  employees.     As  very  few  sick  benefit  societies  existed  in 
Russia  previous  to  the  passage  of  the  Act,  the  administration  of  fie 
system  was  put  exclusively  in  the  hands  of  establishment  or  factory- 
funds,  coiitrolled  by  boards  of  directors  of  which  the  employers  elect 
two-thirds  of  the  members  and  the  employees  one-third.     The,.  Nor- 
wegian law  (1000)  covers  all  industrial  emploj^ees  regardless  of  trade 
and  departs  from  German  precedent  in  exempting  persoiis  suffering 
from   chronic  diseases,   making   medical   care  for   dependents   com- 
pulsory and  introducing  a  definite  money  subsidy  from  the  State. 
The  Netherlands  passed  a  compulsory  health  insurance  law  in  1913,. 
differing  in  two  important  features  from  the  German  law.     No  mes- 
cal or  funeral  aid  is  provided,  because  of  the  already  extensive  pro- 
vision of  this  care  by  mutual  aid  societies  and  by  municipalities; 
and  the  administration  of  the  sj^stem  is  in  the  hands  of  special 
'^labor  councils,"  elected  by  employers  and  employees  for  adminis^ 
trative  districts  designated  by  the  government.     These  councils  pro- 
vide a  method  of  organization  which  more  closely  approaches  com- 
plete  state  insurance  than  the  methods  used   in   otheii  European 
countries*. 

Sweden  is  reported  to  have  adopted  a  compulsory  system  since  tke 
outbreak  of  the  war,  and  Italy  has  appointed  a  Commission  to  draft 
a  compulsory  Act,  including  other  workers  besides  railway  employees, 
who  are  at  present  compulsorily  insured.  In  May,  1014,  the  Belgiai* 
Chamber  of  Representatives  passed  a  bill  for  compulsory  health, 
invalidity,  and  old  age  insurance  which  was  to  have  been  referred  to- 
the  Senate  in  November,  1014.* 


(^)Chambro  dos  Kepresentants,   Amwles  Parleir.ontaires,   page  2,031. 


242 

It  has  of  course  been  impossible  to  secure  extensive  or  detailed 
information  concerning  the  recent  operation  of  any  of  these  systems. 
Their  success  or  failure  can  at  present  only  be  judged  by  the  testi- 
iHony  of  persons  who  are  familiar  with  the  various  countries  con- 
42erned.  By  far  the  largest  volume  of  this  testimony  indicates  a  wide 
spread  endorsement  of  the  principle  of  compulsory  health  insurance 
in  Europe,  and  a  desire  on  the  part  of  all  classes  to  liberalize  benefits, 
extend  eligibility,  and  give  greater  stimulus  to  preventive  health 
measures.  *~~""      ^^ 

In  March  1914,  Sidney  and  Beatrice  Webb,  the  well  known  English 
writers  on  labor  problems,  published  a  careful  report  of  the  results 
of  an  investigation  which  they  had  just  made  of  the  British  Health 
Insurance  system.  They  spoke  very  frankly  of  the  incompleteness 
especially  of  the  medical  care  pjovided,  but  said  of  the  system  in 
general : 

^'We  cannot  pretend  to  measure  the  advantage,  to  individuals  or  to 
the  community,  or  the  really  gigantic  provision  thus  made  for  periods 
of  incapacity — however  far  short  of  completeness  or  perfection  the 
provision  may  be  deemed  . 

''We  do  not  pretend  in  this  survey,  to  give  any  vision  of  the  social 
results  of  the  National  Insurance  Act — to  gauge  the  relief  afforded  in 
sickness  and  poverty,  or  the  advance  in  health  and  productive  power 
that  its  truly  gigantic  operations  can  not  fail  to  be  bringing  about." 


213 


PART  III.     -^ 
SECTION  III. 

State  Social  Insurance  Facilities  in  the  United  States. 

The  industrial  development  of  the  United  States,  as  of  Europe,  has 
been  accompanied  b}^  various  efforts  of  employed  persons,  sometimes 
with  the  cooperation  of  employers,  to  establish  insurance  systems 
T\hich  would  enable  groups  of  woi'kers  to  distribute  such  risks  as 
those  arising  from  sickness,' accident7oT3~agFiiml  invalidity.  Tr^de 
unions,  both  national  and  local ;  establishment  funds  for  workers  in 
individual  industrial  or  TjusTiiess  operations;  mutual  societies,  fra- 
ternals  and  lodges;  and  mutual  industrial  life  insurance  companies 
are  the  best  known  representatives  of  this  type  of  protection. 

The  extent  of  these  different  kinds  of  insurance,  in  so  far  as  they 
are  concerned  with  the  sickness  risk,  has  been  outlined  in  Part  II, 
Section  III  of  this  report.  Their  growth  in  this  country  has  been 
very  similar  to  their  progress  in  Europe  before  the  enactment  of  so- 
cial insurance  acts,  and  they  reveal  here  the  same  defects  as  we 
have  already  described  in  discyssing  the  factors  which  led  to  the 
development  of  state  insurance  abroad. 

A.Jew  interesting  experiments  are  being  made  in  different  parts 
of  the  United  States  with  voluntary  state  insurance  in  very  limited 
degrees.  Massachusetts  through  its  savings  banks  and  Wisconsin 
through  the  state  government  are  attempting  to  provide  industrial 
life  insurance  at  the  lowest  possible  cost  by  eliminating  profit  and 
the  expense  of  solicitors  and  collectors,  and  by  subsidizing  the  cost 
of  actuarial  and  medical  departments.  Indiana  has  for  jnany  years 
maintained  a  ^^hydrophobia  fund,"  from  which  persons  bitten  by 
dogs  can  have  their  wounds  treated,  and  North  and  South  Dakota 
have  just  adopted  from  Canada  a  plan  for  ''hail  insurance,"  main- 
tained by  the  state  for  the  protection  of  the  farmer  in  case  of  de- 
struction of  his  crops  by  hail  storms. 

However,  the  growth  of  Workmen's  Compensation  is  the  one  im- 
portant development  of  state  insurance  in  this  country  so  far.  The 
addition  of  Virginia  in  1918  made  thirty-eight  states,  besides  Alaska, 
Hawaii,  and  Porto  Kico,  which  have  compensation  acts.  The  federal 
government  has  also  a  law  for  the  protection  of  its  million  civilian 
employees,  and  war  risk  insurance  has  been  provided  for  men  in  the 
service.  Thirteen  of  the  stalb  compensation  laws  are  compulsory, 
and  sixteen  laws  provide  for  insurance  in  a  state-managed  fund. 
The  rate  of  compensation  varies  from  40  per  cent  of  wages  in  Wash- 
ington to  6Gf  per  cent  in  Ohio  and  New  York.     Louisiana,  Massa- 


244 

chusetts,  New  York,  Porto  Rico,  Kentuckj',  and  New  Jersey,  liave- 
improved  their  laws  within  the  past  year.  The  smccessful  operation 
•f  these  laws  has  won  general  support  of  the  principle  of  compensa- 
tion, not  only  because  of  the  relief  afforded  actiiaT^^^^^^ 
but  even  more  because  of  the  tremendous  impetus  given  to  preventive' 
efforts.  The  "Salety  First"  sign  is  now  a  familiar  one,  and  is  but 
an  indication  of  the  general  movement  for  safe  working  conditions, 
properly  guarded  machinery,  and  educational  campaigns  among; 
employees. 

STATE  HEALTH  INSURANCE  PROPOSALS  IN  THE  UNITED  STATES. 

Various  plans  for  State  Insurance  have  been  proposed  in  this^ 
country,  differing  somewhat  in  the  number  and  type  of  benetits^ 
provided. 

The^most  comprehensive  proposals  aim  to  insure  all  eniployed  per- 
sons against  sickness  and  accident  not  covered  by  Workmen's  Com- 
pensation acts,  and  to  provide  medical  benefits  during  the  entire- 
illness,  including  the  necessary  supplies  and  hospital  treatment,  ex- 
tendiiii;  tliis  care  to  the  Avorkers'  dependents;  making  special  pro- 
vision for  maternity  and  death  benefits;  supplying  cash  as  well  as 
medical  benefits,  the  cash  benefit  amounting  to  a  proportion  of  the^ 
employee's  Avages,  but  with  a  maximum  limit.  It  is  proposed  to  con- 
duct the  system  under  state  supervision  and  to  support  it  by  contri- 
bution from  the  employees,  the  employers,  and  the '  community,  in 
varying  proportions. 

The  other  proposed  plans  are  usually  modifications  of  the  above^ 
differing  from  it  principally  in  the  regulations  as  to  (1)  whether  in- 
sured persons  shall  include  all  employes,  or  be  limited  to  a  group  in 
receipt  of  not  more  than  a  certain  yearl}^  income;  (2)  whether  bene- 
fits can  be  extended  to  the  dependents  of  these  employees;  (3)  methods- 
of  organization  and  provisions  for  medical  benefits;  (4)  degree  of 
supervision  and  type  of  insurance  carriers;  (5)  detail  in  types  of 
benefits  conferred. 

There  are  two  standards  by  which  any  proposed  health  insurance 
plan  must  be  tested  as  a  state  or  national  policy: 

Fii'st:    Whether  it  will  lessen  poverty  and  destitution. 

Second:    Whether  it  will  lessen  disease  and  promote  health. 

As  Dr.  Warren  of  the  United  States  Health  Service  states,  ^'State 
Health  Insurance  should  have  two  definite  objects:  (1)  to  distribute 
the  eost  of  sickness  among  those  responsible  for  conditions  causing 
sickness  and.  thereby  lighten  the  burden  upon  the  individual  and  (2) 
to  give  a  financial  incentive  for  the  ]l:'evention  of  sickness  to  those 
who  are  responsible  by  dividing  the  premiums  among  the  responsible 
groups." 


245 

Because  of  the  attention  paid  to  the  exact  number  and  kind  of 
losses  occurring  and  the  financial  incentive  to  prevent  as  many  as 
possible  of  these  losses,  we  find  that  invariably  all  kinds  of  insur- 
ance stimulate  prevention.  Life  insurance  companies  find  it  worth 
their  while  to  care  for  the  health  of  tJieir  policy  holders ;  to  make  in 
short,  every  efi'ort  to  prevent  death  and  the  consequent  loss  to  the 
■company.  Fire  insurance  companies  stimulate  in  every  possible 
way  means  of  fire  prevention.  A  certain  number  of  losses — deaths, 
fires,  accident — are  bound  to  occur.  As  a  business  proposition,  how- 
ever, it  is  worth  the  while  of  the  insurance  companies  to  reduce 
the  number  of  these  losses  to  the  minimum.  So  far  as  we  are  able 
to  judge  from  the  information  available,  every  European  country 
which  has  in  operation  a  state  health  insurance  system  has  felt  the 
impetus  to  preventive  eftort.  Better  hospital  and  nursing  facilities 
have  been  provided,,  prompt  attention  to  minor  illnesses  has  lessened 
the  proportion  of  serious  and  chronic  diseases,  and  educational 
health  propaganda  among  the  employed  classes  has  been  greatly 
stimulated. 

TShe  interest  in  State  Health  Insurance  in  the  United  States  is 
witnessed  by  the  innumerable  private  bodies  representing  the  or- 
;ganized  employers,  employees,  medical  profession,  social  agencies 
and  research  bureaus  studying  health  insurance  questions,  in  addi- 
tion to  the  official  commissions  created  by  nine  State  Legislatures 
and  charged  with  the  duties  of  investigating  the  sickness  problem 
among  employed  persons,  the  economic  results  of  this  sickness,  and 
^i:he  different  plans  in  force  in  this  and  other  countries,  looking  to- 
ward a  more  equitable  distribution  of  the  sickness  burden  among 
^hose  responsible  for  it — the  individual,  industry,  and  the  State. 


24G 

PART  III.— SECTION  II.— TABLE  I. 

PRINCIPAL    EUROPEAN    COUNTRIES    HAVING    HEALTH    INSURANCE 
WITH  DATE  OF  ORIGINAL  ADOPTION. 


Compulsory  Geaeral. 


Compulsory  Partial. 


Germany,    ISSr. 

Austria,    1888 

Hungary, 1891 

Luxemburg,  19.71 

Norway,  19C9 

Servia,    1910 

Great  Britaia,  1911 

Russia,    _. 1912 

Roumania,    1912 

Netherlands,    1913 

Belgium,    1914 

Sweden   (reported),    191Y-1S 

Ten  cantons  of  Switzerland,   1914 


la- ante: 

Miners,  seamen,  railway  employees,.  1894 
Denmark: 

Allen  seasonal  employees, _' 190* 

Italy: 

Maternity  cases,  1910 

Voluntary,  Subsidized  by  State 

Denmark, 1SG2: 

France,  1910 

S^^itzerland,     191^ 


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